LIBRARY OF CONGRESS. 

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Chap,..'.... Copyright No. 

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UNITED STATES OF AMERICA. 



THERAPEUTICS 



OF 



INFANCY AND CHILDHOOD, 



A. JACOBI, M.D., 



CLINICAL PROFESSOR OF THE DISEASES OF CHILDREN IN THE COLLEGE OF PHYSICIANS AND 

SURGEONS (COLUMBIA UNIVERSITY), NEW YORK; PRESIDENT OF THE ASSOCIATION 

OF AMERICAN PHYSICIANS ; LATE PRESIDENT OF THE NEW YORK ACADEMY 

OF MEDICINE AND OF THE MEDICAL SOCIETY OF THE 6TATE OF 

NEW YORK, ETC. 




'rftfk 



PHILADELPHIA : 

J. B. LIPPINCOTT COMPANY. 

1896. 



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^ 



Copyright, 1895, 

BT 

J. B. Lippincott Company. 



Electrotyped and Printed by J. B. Lippincott Company, Philadelphia, U.S.A. 



THIS BOOK IS INSCRIBED TO THE CHIEF OF 
MY CLINIC, 



DE. FEANCIS HUBEE, 



IN DUE APPRECIATION OF THE VALUABLE AND UNREMITTING 

SERVICES RENDERED BY HIM THESE FIFTEEN 

YEARS, AS A 

TRUSTED ASSISTANT AND FRIEND 

AND 

EFFICIENT CO-OPERATOR, 

BOTH TO ME AND TO THE COLLEGE OF PHYSICIANS AND 
SURGEONS OF NEW YORK. 



"Die Frucht der Heilung wachst am Baume der Erkenntniss. Ohne 
Diagnostik keine verniinftige Therapie. Erst untersuchen, dann urthei- 
len, dann helfen." — C. Gerhardt. 



PREFACE. 



Much of what is contained in this work may be claimed 
as common property. Much of it I have taught before. In- 
deed, very few books can ever be written that will be entirely 
new. Pediatrics is not new to-day ; nor was it so when, in 
1860, I established the first systematic course, in our country, 
of clinical instruction in the diseases of children. Having 
since that time appeared before the medical public with essays 
and monographs only, I was repeatedly reminded by friends of 
my obligation to submit to the profession which has afforded 
me so many facilities and advantages a compact picture of 
the therapeutics of infancy and childhood as I have it in my 
mind. 

A large part of this work is devoted to diet and hygiene, 
a good deal also to the consideration of the action of medi- 
cines. For, indeed, I believe in medicines. Advancing years 
and experience during a period of increasing exactness in 
medical methods have rather strengthened my belief than 
otherwise. What the knife is to the surgeon, drugs are to the 
physician. The knife does not make the surgeon, nor do 
medicines make the physician ; both, however, are indispen- 
sable. To employ them with benefit takes skill and experience, 
both individual and collective, as also judgment and honesty. 

Indications for the administration of medicines are fur- 
nished by etiology and symptomatology. Both of these oc- 
cupy a prominent place in this book. Without a diagnosis 
of the morbid process and of its evolution, and without the 
appreciation of its influence on the patient, no rational therapy 

5 



6 PREFACE. 

can be thought of. Consequently I have taken particular pains 
to offer clear, though brief, statements of differential diagnoses. 

I have tried to write a book for those who are sufficiently pre- 
pared by previous studies to build their therapeutical measures 
on the foundation of an exact recognition of the conditions they 
have to deal with. It is intended for those to whom neither 
the principles of diagnosis nor the facts of materia medica 
are mysteries. Therefore I have abstained from ornament- 
ing my pages with numerous recipes. While aiming at accu- 
racy in dosing, I have trusted, as regards the actual writing of 
prescriptions, to the knowledge and intelligence of the reader. 
On account of our present period of transition to the metric 
system, I beg to be pardoned for alternating the old methods 
with the new. 

In view of what I have included within the frame of this 
volume, it might almost claim the name of text-book. I 
prefer, however, to call it therapeutics only, intending to em- 
phasize the fundamental truth that everything in medical 
science, in order to be both scientific and humanitarian, should 
be conducive to the prevention or to the cure of disease. 

The preparation of this book has extended over a long 
period. The first essays embodied in it were published in the 
Archives of Pediatries of 1888. As a consequence the reader 
may discover occasional incongruities, which, however, he will 
find to be more those of style than of matter. 

A. Jacobi. 

110 West Thirty-Fourth Street, New York, 
October, 1895. 



CONTENTS. 



PAGE 

I. — Feeding of Sick Children 9 

II. — Treatment of the Newly-Born 38 

III. — General Therapeutics 69 

IV. — Constitutional Disorders 91 

V. — Infectious Diseases 141 

VI. — Diseases of the Digestive Organs 227 

VII. — Diseases of the Genito-Urinary Organs 280 

VIII. — Diseases of the Respiratory Organs 309 

IX. — Diseases of the Organs of Circulation 355 

X. — Diseases of the Nervous System 376 

XI. — Diseases of the Skin 419 

XII. — Diseases of the Ear 439 

XIII. — Diseases of the Eye 448 

XIV. — Diseases of the Muscles 460 

XV. — Diseases of the Bones and Joints 464 

XVI.— Addenda 485 



THERAPEUTICS 



OF 



INFANCY AND CHILDHOOD. 



I. 

FEEDING OF SICK CHILDREN. 

Dietetics must be considered a part of therapeutics. The 
two must always go hand in hand. Sydenham knew the fact 
that many diseases are removed by a correct mode of living, and 
nutrition ; and the men who established therapeutical schools 
on certain positive principles or preconceived ideas, arranged 
their dietetical and their medicinal and surgical rules on the 
same basis. Thus, Broussais, among others, while he purged 
and bled, crowned his work with starvation to such an extent 
that Graves, in 1843, had to come forward with the declaration 
that the systematic starvation of the disease ended in the de- 
struction of the patient. It was Chossat, finally, who proved 
that inanition had many of the symptoms of fever, and that 
a starvation diet was liable to increase its dangers. 

Still, there are no universal rules for feeding, as there are 
none for medication. There are, however, certain indications 
which can always be fulfilled in the treatment of individual 
cases. As intellect and knowledge are required for finding 
those indications, so there is need of tact and experience to 
apply and fulfil them. Some of them are plain enough. It 

9 



10 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

is clear that in conditions of great debility there must be no 
farther reduction of strength ; an irritated cerebrum must not 
be excited ; hemorrhages, peritonitis, dysentery, perityphlitis 
require absolute rest; a hyperaesthetic stomach must not be 
overfed ; a gastro-enteritis resulting from the presence of fer- 
ments must do without milk ; convalescence and acute inflam- 
matory fevers must be protected. Still, there are chronic fevers 
with fair digestion, which permit of generous feeding. All 
these indications and rules are equally valid for both the adult 
and the young. Still, the latter have some peculiarities which 
alter the application of general rules to a considerable extent, 
for several reasons. Of these I shall mention but a few in 
this connection. Habits, which play an all-important part in 
the nosology of adults, such as alcohol, narcotics, sexual 
abuses, are not observed — unless very exceptionally — in the 
child. Cardiac debility, which is the constant danger of the 
senile period, and a frequent one in the adult, is not so fre- 
quent in the very young, partly because the heart is larger 
and more powerful, compared with the rest of the body, and 
partly because it has not had so much time and opportunity to 
become diseased. On the other hand, general metamorphosis 
is very rapid in the young, because of both the rapidity of the 
vital processes, and the constant necessity of adding to the tis- 
sue of the body, besides keeping up the equilibrium. There- 
fore inanition is not tolerated for a long time. Thus the 
child cannot long remain without being fed, and, therefore, its 
digestive organs require permanent attention. Their physi- 
ology must be carefully studied in both the healthy and mor- 
bid conditions. What the child eats is of but little conse- 
quence compared with what it digests. Nor are its subjective 
sensations the proper guides for the selection of foods or the 
times of feeding. It is not always true that where there is 
no appetite there is no digestion. Nor are the pangs of 
hunger or the temptations of cravings safe counsellors. Nor 



FEEDING OF SICK CHILDREN. 11 

does the condition of the tongue, to which we are apt to turn 
as one of our advisers in many of the ailments of the adult, 
deserve of the same confidence in the young, for the frequent 
local processes inside the oral cavity are very apt to mislead us. 

From the very first month of life a distinct diastatic effect is 
produced by the oral secretion ; it increases with every month. 
Even infusions of the parotids, prepared at different times 
after death, produce the same effect. Infusions, however, of 
the pancreas taken from the bodies of infants who have lived 
three weeks, produce no such changes. The diastatic power of 
the pancreas begins with the fourth week only, and remains 
feeble up to the end of the first year. 

Zweifel experimented with infusions of different glands. 
That of the submaxillary glands of an infant did not trans- 
form starch into sugar, even after the lapse of a whole hour. 
The effect of an infusion of the parotid of a baby seven days 
old was distinct after four minutes; however, that of the 
parotid of a baby which had died at the age of eighteen days, 
of gastro- enteritis, did not show itself until the lapse of three- 
quarters of an hour. Nor was a diastatic result obtained by a 
similar infusion made of the parotids of a baby prematurely 
born, and one who died of diarrhoea and debility. 

It is a remarkable fact that different varieties of starch are 
not changed by saliva into grape-sugar in the same length of 
time. In reference to the time required, however, there is no 
uniformity of opinion. Solera found that the transformation 
of the starch of the potato was the most rapid. Next came 
that of Indian corn, next wheat, and the transformation of 
the starch of rice was the slowest. According to Malay, raw 
starch changes slowly, boiled starch quickly. According to 
him, that of the potato required from two to four hours; that 
of wheat from one-half to one hour; of barley from ten to 
fifteen minutes; of oats from five to seven minutes; of rye 
from three to six minutes ; of potato paste five minutes. 



12 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

It is important to know that the effect produced by saliva 
persists in the stomach for a period of from one-half to two 
hours. But it ceases altogether, and starch will no longer be 
changed into grape-sugar, inside the stomach as soon as the 
secretion of hydrochloric acid has begun in the digestive 
process. This is a very important fact, because it shows that 
the farinaceous food of the infant or child, though it be not 
masticated, and pass the mouth very rapidly, is still under the 
influence of the saliva in the stomach, for some time. 

Hydrochloric acid is not secreted at once. The first acids 
in the stomach while digestion is going on are organic, mostly 
lactic. This is found to be contained in that organ when gas- 
tric juice is removed from it in the first period of digestion. 
Thus in a gastrostomized boy UfFelmann found under nor- 
mal circumstances, and in the absence of fever, during the 
first half-hour, lactic acid only ; afterwards hydrochloric acid.* 
The latter is not met with during fever and a considerable 
degree of gastric catarrh (and also in dilatation of the stomach 

* This agrees with what Ewald and Boas published lately as the result 
of their experiments also. But they claim to have found hydrochloric 
acid only, when a decoction of starch alone was introduced into the 
stomach. Still later Th. ^Rosenheim (Centralbl. f. d. Med. Wiss., Novem- 
ber 12, 1887) reports as follows, after the ingestion of fifty grammes of 
bunn and one hundred and fifty of water : Free hydrochloric acid 
makes its appearance in the healthy stomach very early, 0.3 p. m. after 
fifteen minutes, 1.0 p. m. after thirty minutes. This quantity or more is 
found until the elimination of chyme has been completed. From begin- 
ning to end there is lactic acid to a uniform amount, viz., 0.3 p. m. In 
carcinoma there was but 0.1 p. m. of hydrochloric acid, in hyperacidity 
1.0 p. m. In every case and in every period of digestion there was lactic 
acid. There was less hydrochloric acid (but 0.2 p. m. after an hour) and 
a fair amount of lactic acid when carbo-hydrates only were taken, no 
matter whether saliva was admitted to, or excluded from, the stomach. 

These data are here added for the purpose of showing that the diffi- 
culties of arriving at absolute facts are exceedingly great. Still, the 
results of the three observers do not differ too much from the accepted 
doctrine. 



FEEDING OF SICK CHILDREN. 13 

resulting from constriction of the pylorus). In these condi- 
tions farinacea (amylacea) are taken to advantage, principally 
because the diastatic effect of saliva is not disturbed. 

Some of the main points to be remembered from the fore- 
going are these : 

There is diminution or absence of saliva from the parotid 
in the very young suffering from diarrhoea and debility. Thus 
the very young ought to have but little starchy food, or some- 
times none at all in these conditions, particularly as the pancreas 
cannot be relied on for diastatic action in the first weeks. 

Whatever saliva, however, has been secreted and is swal- 
lowed, continues its action in the stomach as long as there is 
no hydrochloric acid in it. This in the healthy is secreted 
only after half an hour or later. In the feverish and catarrhal 
stomach very much later or not at all. Thus what saliva is 
present, displays its diastatic action continually. Thus the 
food craved for and digested is farinaceous. Animal food 
which requires hydrochloric acid is not wanted, nor is it readily 
digested. 

To discuss here all the functions of the stomach is not neces- 
sary. In anaemia, convalescence, particularly in fevers, they 
are impaired. Both pepsin and hydrochloric acid are wanting. 
To increase their secretion large quantities of water are re- 
quired. 

Infants' food ought to be mixed with large quantities of 
water, for reasons given on other occasions, under ordinary cir- 
cumstances. In diseased conditions of the stomach the free 
dilution of children's nourishment with water is demanded 
upon the following additional facts. Only to a certain limit 
will pepsin be furnished for digestive purposes. Probably a 
portion of this is not entirely utilized, because a great quan- 
tity of water is necessary to assist in pepsin digestion. In 
artificial digestion albumin often remains unchanged until 
large quantities of acidulated water are supplied. Without 



14 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

doubt many disturbances of digestion are to be explained by 
a deficiency of water, certainly many more than are due to an 
excess of it, for the latter is speedily relieved by rapid absorp- 
tion. 

For the reasons given, I advocate under all conditions a 
plentiful addition of water to children's food. In this con- 
nection I would lay stress upon the fact that, as a rule, small 
children receive water only as they get it in their milk or 
milk food. Alike in summer and in winter, it is probable 
that the fact seldom occurs to a mother or nurse that a child 
may be thirsty without being hungry at the same time. Cer- 
tainly many a discomfort and even sickness in a child is con- 
ditioned upon the fact that it has been compelled to eat in 
order to get its thirst satisfied, and often has to suffer thirst 
because the over-stimulated and injured stomach will take no 
more nourishment at irregular and too short intervals. There 
are even normal products of digestion capable of disturbances 
in the digestive process, chief among which is peptone itself, 
which is not absorbed unless it be greatly diluted. I have, 
therefore, considered it necessary in preparing the rules for 
the feeding of children, which the New York Health Depart- 
ment has annually published and distributed since 1872, to 
insist upon giving infants who cannot ask in so many words 
for it, an occasional drink of water, at least during the hot 
weather. When there is the least ground for the supposition 
that the drinking-water is contaminated with germs of dis- 
ease, or where it is unusually hard, it should be boiled before its 
admixture with children's food, whether the diet be milk or 
a mixed one. In general it will give greater satisfaction to 
use the boiled water systematically, even though there be no 
apparent urgency for it in the cases of very young infants. 

There are many other indications for the administration of 
water in the diseases of the young. In many morbid condi- 
tions it is wanting. Perspiration, diarrhoea, general inanition, 



FEEDING OF SICK CHILDREN. 15 

feverish diseases, diminish its quantity in the tissues and blood- 
vessels. Thus an inspissation of the blood takes place, throm- 
boses form in the small veins of distant parts or the viscera, 
in the brain they lead to convulsions and defective innerva- 
tion (hydroencephaloid), in the limbs to oedema or gangrene. 
The remedy is water in sufficient quantities. Where the 
stomach rebels, the hungry lymph-ducts of the rectum will 
greedily absorb an ounce or much more, injected every hour 
or two. In many a case life is saved in this manner. 

Where general metamorphosis is slow, water in abundance 
increases the elimination of urea and carbonic acid. Where 
the urine is scanty and of an undue specific gravity, water 
protects the kidneys from undue irritation. It acts on the 
mucous membranes as it does on the external integuments. 
In laryngitis and bronchitis it liquefies viscid expectoration, in 
many forms of constipation it acts beneficially by increasing the 
secretion of the muciparous glands of the intestines. Ice and 
ice-water, or iced carbonated water, in small quantities, but fre- 
quent doses, relieve hyperesthesia of the stomach and stop 
vomiting. Warm water acts as an emetic, hot water injected 
into the rectum combats collapse. In this very connection, 
however, I may allude to what good may be done by absti- 
nence from water. In some forms of acute gastro-enteritis, 
where vomiting and diarrhoea are excessive, the only salvation 
is in total abstinence for from four to eight or ten hours. Not 
infrequently the turning-point in the course of the threatened 
danger dates from the commencement of what appears to be 
cruel starvation. 

A regular addition to the milk food of infants' and children 
is that of sugar. Its percentage in the milk of the woman, 
ass, and mare is larger than that of the cow. Immediately 
after the milking of the cow the milk-sugar begins to be 
changed into lactic acid. This process, together with the 
gradual conversion of fat into acid, is the cause of curdling. 



16 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

The large amount of sugar in woman's milk, together with 
its smaller percentage of casein and butter, gives it the peculiar 
bluish color and furnishes the colostrum, which contains plenty 
of salts besides, its tendency to loosen the bowels. This 
property becomes manifest, sometimes, under abnormal cir- 
cumstances. Thus in the milk of anaemic women sugar is 
occasionally found to an unusual degree. In their cases the 
other solid matters may also be diminished, still, this is not 
uniformly so. The infants, however, suffer often from obsti- 
nate diarrhoea. 

The conversion of milk-sugar into lactic acid takes place 
very rapidly. When it takes place in cow's milk this turns sour 
at once. Not infrequently is it sour from the first ; it has been 
found to be so in the udder ; in most cases it is " amphoteric," 
neutral. Thus the question arises what kind of sugar is to be 
used as the addition to the food of children both well and sick. 

Cane-sugar is not so easily transformed. Indeed, it is util- 
ized for the purpose of counteracting the rapid conversion of 
milk-sugar, and for the preservation of articles of food in 
general. Trade is not so slow in availing itself of the results 
of organic chemistry as the profession. Condensed milk re- 
mains intact a long time on account of the plentiful addition 
of cane-sugar, in spite of the original presence of milk-sugar 
in it. Therefore it is not at all an indifferent matter whether 
milk-sugar or cane-sugar be added to the food of infants and 
children. I have always insisted upon the selection of the 
latter for that purpose. 

In the sick the absorption of sugar is slower than in the 
healthy. Besides, during most diseases, particularly those of 
the alimentary canal, there is more ferment in the mouth 
and stomach. Thus but little sugar ought to be given, and 
never in a concentrated form. Grape-sugar and dextrin are 
absorbed equally. Cane-sugar, according to Pavy, is partly 
inverted and partly absorbed. All appear to be changed, 



FEEDING OF SICK CHILDREN. 17 

when given in moderate quantities, into carbonic acid and 
water, even during moderate fevers. 

In that form of constipation of small infants which depends 
on a relative absence of sugar and superabundance of casein; 
in the breast-milk, the addition of sugar acts very favorably.. 
A piece of loaf-sugar (a teaspoonful or less) dissolved in 
tepid water (or oatmeal water) must be given before each 
nursing, and will often prove the only remedy required to 
regulate the bowels. 

The physiological effect of chloride of sodium is very 
important, no matter whether it is directly introduced through 
the mother's milk, or added as a condiment to cow's milk, or 
vegetable diet. Both of the latter contain more potassium 
than sodium, and neither ought ever to be given, to the well or 
sick, without the addition of table-salt. A portion of that 
which is introduced may be absorbed in solution ; another part 
is, however, broken up into another sodium salt, and hydro- 
chloric acid. Thus it serves directly as an excitant to the 
secretion of the glands, and facilitates digestion. Therefore 
during diseases in which the secretion of gastric juice is inter- 
fered with, or in the beginning of convalescence, when both 
the secreting faculties and the muscular power of the stomach 
are wanting, and the necessity of resorting to nitrogenous food 
is apparent, an ample supply of salt ought to be furnished. 
The excess of acid which may get into the intestinal canal 
unites with the sodium of the bile in the duodenum, and assists 
in producing a second combination of chloride of sodium, 
which again is dissolved in the intestines and absorbed. Its 
action in the circulation is well understood: it enhances the 
vital processes, mainly by accelerating tissue-changes through 
the elimination of more urea and carbonic acid. 

A very important fact is also this: that the addition of 
chloride of sodium prevents the solid coagulation of milk by 
either rennet or gastric juice. Thus cow's milk ought never 

2 



18 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

to be given without table-salt, and the latter ought to be added 
to woman's milk when it behaves like cow's milk in regard to 
solid curdling and consequent indigestibility. 

Habitual constipation of children is also influenced bene- 
ficially, for two reasons : not only is the food made more digest- 
ible, but the secretions of the alimentary canal, both serous and 
glandular, are made more effective by its presence. 

A certain amount of fat is digested even in fevers of mod- 
erate severity, thus also in typhoid fever. But it is a good rule 
to rather reduce its quantity, because when infants were fed on 
cow's milk during capillary bronchitis, the fat in the faeces 
amounted to forty per cent, of the solid constituents. A few 
additional remarks will render the subject clearer, and show 
that it is very easy to give too much fat. 

There is a large amount of faeces, although the baby receives 
absolutely nothing but mother's milk. What has been called 
detritus in the fseces is not exclusively undigested casein, but 
principally fat and large masses of intestinal epithelium. 
This so-called detritus is not soluble in water, acids, or alka- 
lies, but quite soluble in alcohol and ether. 

Casein is present only when it has been taken in too large a 
quantity, or when there is too much free acid in the stomach. 
In those cases there are large quantities in the fseces. 

An important practical application of this fact is the follow- 
ing : As it is true that fat is not completely absorbed, even 
under the most normal circumstances ; as free fat acids are so 
easily formed and accumulated; as they are found in moderate 
quantities, even in healthy babies ; as a surplus is very apt to 
derange digestion and assimilation, and to prevent the normal 
secretion of either of the digestive fluids ; as there is a super- 
abundance of fat in the normal food of the nursling, the con- 
clusion is justified that we should be very careful in preparing 
foods for the healthy or sick. It is very easy to give too much 
fat. It is hardly probable that there is too little. 



FEEDING OF SICK CHILDREN. 19 

Under the head of " Fat Diarrhoea" German journals and 
a few text-books speak of a diarrhoea, the chief characteristic 
of which is the presence of a large quantity of fat in the 
stools. 

The normal faeces of the newly-born contain ten or twelve 
per cent., sometimes more, of fat. In abnormal cases, even 
when the food does not contain it, the faeces may contain from 
forty to seventy per cent, of fat. 

The microscope reveals in serious cases fat, almost to the 
exclusion of everything else, sometimes pure, and other times 
in more or less regular needles. The anatomical condition in 
fat diarrhoea may vary, but in the majority of cases we have 
to deal with a simple catarrh of the intestinal tract. There 
are changes in, and exfoliation of, the epithelium of the small 
intestine, swelling of the mucous membrane of the duodenum, 
with obstruction to the flow of the secretions of both liver 
and pancreas, and such hyperplasia of the mesenteric lymph 
bodies as to impede the absorption and circulation of chyle. 
Finally, in a very few instances, anatomical changes were 
found in the pancreas resembling those which in the adult 
interfere with the emulsion of fat. 

No improvement is possible unless the quantity of fat 
contained in the food be largely diminished. The administra- 
tion of cream and the routine treatment with cod-liver oil are 
equally injurious in these cases. 

In feeding the sick no new principles must be sought for. 
The sick child is still the child, and the physiological laws 
hold their own under changed circumstances. No new articles 
of food can be discovered or invented, only the preparation or 
mixture of those in ordinary use may change temporarily, or a 
restriction in their number or amount take place. Thus, I 
cannot undertake to give in full the methods of feeding in- 
fants and children. In several previous publications have I 
done so, and must refer to them. I will only repeat a few 



20 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

rules, leaving the reasons for them to the thoughtful ness or 
the recollection of the reader. 

The principal substitutes for breast-milk are those of the 
cow and the goat. The mixed milk of a dairy is preferable 
to that of one cow. Cow's milk must be boiled before being 
used. Condensed milk is not a uniform article, and its use 
precarious for that and other reasons. Goat's milk contains 
too much casein and fat, besides being otherwise incongruous. 
Skimmed milk obtained in the usual way, by allowing the 
cream to rise in the course of time, is objectionable, because 
such milk is always acidulated. The caseins of cow's and 
woman's milk differ both chemically and physiologically. 
The former is less digestible. There ought to be no more 
than one per cent, of casein in every infant food. Dilution 
with water alone may appear to be harmless in many in- 
stances, for some children thrive on it. More, however, ap- 
pear only to do so ; for increasing weight and obesity are not 
synonymous with health and strength. Abetter way to dilute 
cow's milk, and at the same time to render its casein less liable 
to coagulate in large lumps, is the addition of decoctions of 
cereals. It has been stated before, that a small amount of 
starch is digested at the very earliest age. But cereals con- 
taining a small percentage of it are to be preferred. Barley 
and oatmeal have an almost equal chemical composition ; but 
the latter has a greater tendency to loosen the bowels. Thus, 
where there is a tendency to diarrhoea, barley ought to be pre- 
ferred ; in cases of constipation, oatmeal. The whole barley- 
corn, ground for the purpose, should be used for small chil- 
dren, because of the protein being mostly contained inside and 
near the very husk. The newly-born ought to have its boiled 
milk (sugared and salted) mixed with four or five times its 
quantity of barley-water, the baby of six months equal parts. 
Gum arabic and gelatin can also be utilized to advantage in 
a similar manner. They are not only diluents, but also nu- 



FEEDING OF SICK CHILDEEN. 21 

trients under the influence of hydrochloric acid. Thus in 
acute and debilitating diseases which furnish no, or little, hy- 
drochloric aeid in the gastric secretion, a small quantity of the 
latter must be provided for. 

Such practitioners and authors who convinced themselves of 
the ill success often attending the use of milk, or watered milk, 
commenced at an early period to mix it with MEAT-soups, 
meat-tea, or egg. Bretonneau reported, as early as 1818, that 
" tabes niesenterica" disappeared, in the hospital of Tours, 
from among the children fed on beef-soup and milk. This 
mixture Vauquelin declared to come nearest to mother's milk 
of all preparations. The administration of some beef-soup, 
well made, a cupful every day (mutton-broth when there is 
a tendency to diarrhoea), is advisable towards the end of the 
first year. Long before this period, indeed at any time during 
infancy, it is indicated in cases of early rhachitis, rhachitical 
constipation, undue adiposity, and retarded teething. 

Beef- tea, well made, in a bottle swimming in the water- 
bath, is still believed by some to be the model food. That it 
is not so rich in soluble albuminoids as was believed, ought to 
be generally understood by this time. What, however, it does 
contain in large quantities, is salts. Thus it is a dangerous 
article in summer diarrhoea, and must never be administered 
by itself. When given at all, it ought to be in combination 
with farinacea, raw albumin (which in this mixture requires 
very little salt, if any). 

Beef-broth is about as nutritious as whey, and no more. But 
on account of the extractive substances of beef, kreatin and 
kreatinin, it is more stimulating. The temperature of the 
body is not raised by it. In gastric irritation, gastritis, and 
acute dysentery it ought not to be given. Veal-broth is 
liable to increase diarrhoea, mutton-broth constipation, and is 
therefore preferable in cases of diarrhoea. A broth of beef, 
which contains from 1.5 to 2 per cent, of albumin, is made by 



22 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

mixing one part of beef and six of water with a little chloride 
of sodium and allowing it to stand from ten to twelve hours. 
Then it is slowly boiled and the whole mass pressed out. Still 
better is a modification of Liebig's beef-tea, which is obtained 
by adding one half-pint of water, with six or seven drops of 
dilute muriatic acid, to a quarter- or one-half of a pound of 
finely-cut lean beef, stirring it occasionally during two hours, 
and boiling a few minutes. Beef-juice obtained by pressing 
out beef after slightly broiling it, contains from six to seven 
per cent, of albumin. It is slightly acid, and spoils 
quickly. 

The peptonized beef preparations are available both inter- 
nally and for rectal alimentation. Of the good specimens in 
the market I have been in the habit of using mostly Leube- 
RosenthaPs beef solution and Rudisch's (Parke Davis) sarko- 
peptone. Either may be mixed with hot water or hot broth; 
a few teaspoonfuls and upwards are valuable additions to the 
daily food. The former is taken by many undiluted in small 
quantities; those who object to it because of its strong aromatic 
taste and odor, will still relish it when quite cold. Valentine's 
preparation is weak, but very palatable. 

Scraped beef, raw, has been highly recommended in the 
chronic stage of, and convalescence from, exhausting gastro- 
enteric catarrh these forty years. It is very digestible, and 
but for the danger of giving rise to tsenia mediocanellata, a 
valuable addition to our means of restoring health. White 
meats contain less fat, hsemoglobin, and extractive material 
than beef. Sweetbread (thymus), 22 per cent, of albumin, 6 
gelatin, but 0.4 fat, 1.6 salts, and 70 .water. 

Ego has been utilized as an admixture to milk, or as its 
substitute, in a great many ways. Both the yelk and the 
albumin have been so employed. The white of an egg f with 
a little salt and six ounces of water, well beaten and shaken, 
is a good mixture, which can take the place of infant food 



FEEDING OF SICK CHILDREN. 23 

only temporarily, but is an invaluable make-shift in severe 
intestinal catarrh, or a permanent nutriment in the same, when 
added to other food. 

Falkland skims milk, and transforms it by means of pepsin. 
The process does not recommend itself to general use by its 
circumstantiality. Eoberts heats milk to nearly a boiling- 
point, and treats it with liquor pancreatis and bicarbonate of 
sodium. Fairchild's method of peptonizing milk is generally 
understood all over the country and is widely appreciated. In 
this connection I may be permitted again to refer to Dr. J. Ru- 
disch's method of improving cow's milk for the use of children 
and adults, sick and well, particularly those who suffer from 
gastric catarrh and do not digest milk in its usual composition. 
It consists in mixing twenty-five minims (half a teaspoonful) 
of dilute hydrochloric acid with a pint of water and a quart 
of milk. When this mixture is boiled but a few moments it 
keeps well, and is quite palatable and highly digestible. 

Alcohol has conquered its place among the medicinal 
foods in the diseases of infancy and childhood. Very little, 
if any, is required in catarrhal, or the first stages of inflam- 
matory, diseases. It is contraindicated in meningitis, acute 
cardiac ailments, gastro-enteritis, peritonitis, and acute dysen- 
tery. It finds its application in depressed strength and vi- 
tality ; thus, in the rules for the management of infants during 
the hottest days of summer, which the Health Department of 
the city of New York has published annually these fifteen 
years, I recommended the administration of a teaspoonful of 
whiskey daily. It is also required in chronic diseases and 
slow convalescence. 

Its action is stimulant, nutritive, antipyretic, and antiseptic. 
It is decomposed into carbonic acid and water, and thus saves 
the waste of material parts of the body. When given in 
sufficient quantities, it reduces the temperature; the amount 
required for that purpose is, according to Binz, forty grammes, 



24 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

corresponding with about three ounces of brandy or whiskey. 
Its most beneficial action is exhibited in sepsis of all forms, 
mainly also in the septic variety of diphtheria. It is almost 
impossible to give too much. The doses must be watched so 
as to be sufficiently large. Whoever is not afraid of giving 
six ounces of whiskey daily to a child when one or two fail, 
or ten or twelve when six fail, will soon convince himself of 
its power for good. It must never be given in concentration; 
the gastric mucous membrane tolerates no pure brandy or 
whiskey for any length of time ; they must be diluted with 
either water or milk properly prepared. Wines, brandies, and 
whiskeys are not equivalent. The latter is obtained pure 
with greater facility, and at less expense, and besides has, for 
many, a less disagreeable taste than either of the others, which 
are often adulterated. The ether contained in wines militates 
against any antifebrile effect which may be expected from it; 
the fusel oil with which brandies are too frequently adulter- 
ated, acts rather as a paralyzing than a stimulating agent. 

Dyspepsia is one of the functional disorders of the stomach, 
and depends sometimes upon slight changes in the gastric mu- 
cous membrane. It consists in partial or complete loss of ap- 
petite, with more or less impaired digestion. In regard to 
this, however, in every individual case, it is good not to rely 
too implicitly upon the reports of mothers or nurses. Older 
children will complain of precordial heaviness. They will 
suffer, as do infants also, from eructations, which, when they 
result from swallowing air, are absolutely odorless, but when 
they consist of actual gastric gases, have a very faint odor. 
A sensation of oppression and frontal pain is complained of 
by older children ; the younger ones are apt to vomit. 

The causes of dyspepsia must be sought for either in anato- 
mical changes in the organ, which can rarely be proven ; or 
(more frequently) in quantitative or qualitative changes in the 
secretion ; or in a changed nervous influence, as, for instance, 



FEEDING OF SICK CHILDREN. 25 

in fever; or in an abnormal condition of the food, which is 
the most frequent cause. 

The treatment of this disorder consists chiefly in abstinence 
or in the use of the greatest care in the preparation of meals. 
Milk requires boiling, peptonizing, or treating with muriatic 
acid according to the method I have detailed before. In every 
case the admixture of farinaceous decoctions and a little salt 
improves the digestibility of milk though prepared as de- 
scribed. In many the latter alone, with or without a meat 
soup, will be the only food which is tolerated. The gastric 
secretion of infants who have been fed artificially, is liable to 
be hyperacid. Alkalies should be given at once. The addi- 
tion of a few grains of bicarbonate of sodium (baking-powder) 
to the food may suffice. A few grains of an alkali (magnesia, 
sodium, calcium, according to the indications explained else- 
where) given a few minutes before every meal, act more surely. 

Vomiting has been mentioned among the symptoms which 
accompany dyspepsia. In the infant, however, it is almost a 
normal occurrence. The infantile stomach is vertical and 
cylindrical, and the fundus but little developed. Thus, when- 
ever there is a tendency to empty the stomach the antiperi- 
staltic motions do not press against the fundus, but directly 
upwards. There is, therefore, less genuine vomiting than a 
mere overflow of the contents, which takes place so easily that 
the babies are not disturbed by it. 

The treatment of such cases, if treatment be required at all, 
would consist in the application of some dietetic rules. The 
infant should have less food, and at longer intervals ; should 
not be carried about immediately after meals; ought not to be 
shaken or jolted ; nor carried face downwards. 

This overflow takes place, as a rule, immediately after the 
baby has been nursed ; at that time the milk is still fluid. If 
vomiting occur a little later, the milk will be coagulated; if, 
then, the milk be not coagulated, the stomach is not in a normal 



26 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

condition. In these cases, and particularly when the baby lives 
on artificial food, there is uneasiness and pain associated with 
the vomiting. An acid mucus is expelled, together with the 
contents of the stomach ; these are the cases in which antifer- 
mentatives, such as nitrate of silver, bismuth, resorcin, are 
indicated. Sometimes antacids alone will suffice, as detailed 
before. 

Gastritis. Acute Gastric Catarrh. — The feeble, the 
anaemic, the convalescent, and the feverish are predisposed to 
this affection. But it may occur in the previously healthy as 
well. In all such children the production of normal gastric 
acid is diminished, and digestion impaired thereby. Besides, 
in all of them, the muscular power of the stomach is reduced. 

Cold or hot ingesta, too large quantities of food, acids, spices, 
irritant medicines, alcoholic drinks, fat meat, cake, decomposed 
food with its ferment, each may be the cause of acute gastric 
catarrh, and must be carefully avoided ; dentition, as such, is 
not a cause. Exposure to changes of temperature is apt to 
produce gastritis, but the usual cause is improper food. A 
single small meal, consisting of, in that case, indigestible food, 
increases pain, vomiting, and fever. Abstinence and cold water 
to the head act well when there is a tendency to convulsions. 
Cold applications to the heart will also reduce the temperature 
of the whole body. A warm bath will frequently do good. 
I do not, however, advise bathing or handling the child much 
while the convulsion is lasting. When thirst is very great, small 
quantities of ice-water should be given often, or seltzer-water, or 
Vichy, or Apollinaris ; also water to which dilute muriatic acid 
has been added in the proportion of one to three or ten thousand. 

Solid food must not be given. When there is a great deal 
of mucus, milk must be given very much diluted, or prepared 
after Rudisch's method. 

When the tendency to vomit is great, food and drink 
must be given in teaspoonful doses, and, where the sensitive- 



FEEDING OF SICK CHILDREN. 27 

ness of the stomach is very marked, mucilaginous and farina- 
ceous foods only will answer, together with small doses of 
bismuth repeated every one or two hours. 

Where acid is predominant, calcined magnesium will answer 
best, if given in small doses frequently repeated ; also bicar- 
bonate of sodium, and very small doses of opium, one-sixtieth. 
to one hundred and fiftieth of a grain, every hour or two hours. 

Chronic Gastric Catarrh is either the result of an 
acute catarrh, or of the continuation of injurious influences. 
Large and frequent meals, too cold or too hot food, and fast 
eating are frequent causes. The stomach may be either in a 
hypersemic or in an ansernic condition ; it may be hyperaesthetic 
or atonic. Its secretion may be faulty or deficient. All of these 
changes may take place in the stomach without any complica- 
tion on the part of neighboring organs, or these may be the 
only, or partial, causes of the gastric disorder; thus pre-emi- 
nently cardiac or pulmonary ailments, which result in impaired 
circulation of the distant organs. Thus many a chronic catarrh 
of the stomach, both in the young and adult, requires among 
its first indications a proper attention to the original cause. 
At all events, the number of meals and amount of food must 
be adapted to the digestive powers. Medication can do good 
service in most cases, either such as is directed to the mucous 
membrane itself (alkalies, bismuth), or to its faulty secretion 
(pepsin with muriatic acid, resorcin), or to the debilitated con- 
dition of its muscular power (strychnia). At all events, the 
children must be taught to eat slowly. Their food must be 
tepid, and not too much diluted, inasmuch as absorption in 
many cases is slow. Sugar, fat, and starch must be allowed 
in small quantities only. 

Ulcerations of the stomach (and duodenum) demand that 
the organs should be kept as alkaline as possible. Abnormal 
acids (acetic, butyric, caprylic, or lactic in excess) must be 
neutralized before food is given. An occasional antacid is 



28 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

not sufficient to obtain that end ; it must be given regularly, 
every two or three hours, also a few minutes before a meal. 
Sodium and magnesium salts, which contain carbonic acid, 
must not be given regularly. That gas produces peristalsis. 
Calcined magnesia answers best in doses of one or two grains, 
administered every hour, or every two or three hours, in 
water which must not be too cold. Hot water is even better. 
More than that quantity is seldom tolerated because of its 
purgative effect (which, however, is very welcome in patients 
with a tendency to constipation). When a larger quantity of 
antacids is required, carbonate or phosphate of calcium may 
be added to the magnesium, with or without the subnitrate or 
subcarbonate of bismuth.* That medicinal treatment must 
be continued through weeks or months. Without it I see no 
gastric or duodenal ulceration getting well, in spite of the most 
careful dietetic regulations. 

The very function of the diseased organ is a great danger. 
Both stomach and duodenum must be kept as idle as possible, 
and their labors made easy. No indigestible food must be 
given, no solid food permitted. Most cases in older children 
bear boiled milk (in some mixed with a little bicarbonate of 
sodium), strained oatmeal or barley gruel, rice or arrow-root 
water, and stale wheat-bread ; a few, also, raw beef, scraped. 
Some tolerate nothing but boiled milk, or buttermilk. There 
are those who prefer kumyss, matzoon, peptonized milk, or that 
prepared with muriatic acid. Whatever they take must be 
swallowed slowly. Milk, when drank hastily, is liable to co- 
agulate in big, hard lumps, and proves indigestible and injuri- 
ous. The same milk, when taken by the mouthfuls, or from 
a spoon, will prove beneficial. The milk must be boiled in 

* The effect of lime-water is in part imaginary. If given for the pur- 
pose of neutralizing acids, it is a failure. Its beneficial action on other- 
wise indigestible cow's milk cannot depend on the minute dose of the 
antacid contained in it. 



FEEDING OF SICK CHILDREN. 29 

the morning, and heated over again several times during the 
day. It must not be cold when taken, and maybe mixed with 
a little table-salt. Many prefer, and tolerate best, the mixture 
of milk and cereal decoctions. Such must be the food for weeks 
and sometimes for months ; the meals must be small and more 
numerous. Thus the patients will get well, and thus only. 

Acute and Chronic Enteritis, Intestinal Ca- 
tarrh, with diarrhoea as a prominent symptom, compare with 
acute and chronic gastritis in their mutual relation. Acute 
catarrh of some duration extends mostly over the whole intes- 
tine; its worst cases are also complicated with the same condi- 
tion of the stomach. The most serious forms are those of " acute 
gastro- enteritis." In them the diet must be a very strict one. 
No raw milk y no boiled milky no milk at all in any mixture, in 
bad cases. In the very worst cases total abstinence for from one 
to six hours, or much longer; afterwards, teaspoon doses of 
a mucilaginous or farinaceous decoction from time to time. A 
good preparation is the following: Five ounces of barley- 
water, one or two drachms of brandy or whiskey, the white 
of one egg, salt, and cane-sugar ; a teaspoonful every five or 
fifteen minutes, according to age or case. Later on, a table- 
spoonful of boiled milk may be added. The same may be 
mixed with mutton-broth, which, with the white of egg, is 
better than beef-soup or beef-tea in convalescence. In vom- 
iting abstinence is mostly superior to ice; the latter may 
sometimes quiet the stomach, and feel pleasant momentarily, 
but it stimulates peristalsis. Beef-tea, in its customary prepa- 
ration, ought to be avoided. In convalescence, when given at 
all, it ought to be mixed with barley- or rice-water. Towards 
the end of the disease, or when the discharges are numerous 
and copious, the blood becomes inspissated, the circulation 
slow, and thromboses (hydro-encephaloid) form in the smallest 
veins of distant organs. Then it becomes necessary to introduce 
liquid into the circulation by administering water through 



30 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

mouth or rectum. Never is the common sense and tact of the 
intelligent practitioner more thoroughly taxed. In regard to 
that there can be no law. No printed rule ever supplies or 
substitutes brains.* 

In chronic cases boiled milk must form but a small part of 
the food. The white of eggs in water, or barley- or rice-water, 
is superior. Still, there are exceptional cases in which even it 
is not tolerated. Then the cereal and farinaceous preparations, 
with or without mutton-broth, are preferable. In rare cases 
one of the better artificial foods is quite successful. Acorn 
coffee, acorn cocoa, answer well when given once or twice 
daily. The meals must be small, and may be more numerous, 
but a fair regularity must be kept up. 

Constipation may have many causes. The intestinal mu- 
cus may be deficient or too viscid. Such is the case in febrile 
conditions, now and then in chronic intestinal catarrh, and also 
when there is too much perspiration and secretion of urine. 
Or the food may be inappropriate, as when it contains a super- 
abundance of casein, particularly in cow's milk, or of starch, 
or too few salts, or of sugar. 

Peristalsis may be incomplete through rhachitic debility 
of the muscular layer, or the muscular weakness dependent 
upon sedentary habits, chronic peritonitis, intestinal atrophy, 
and hydrocephalus. 

There is, also, beside mechanical obstruction by cystic 
tumors, intussusceptions, volvulus, and imperforations, an ap- 
parent constipation which ought not to be mistaken for any of 
the above varieties. Now and then a child will appear to be 
constipated, have a movement every two or three days, and at 
the same time the amount of faeces discharged is very small. 
This apparent constipation is seen in very young infants rather 
than in those of more advanced age. Such children are ema- 

* Med. News, July 9, 1887. 



FEEDING OF SICK CHILDREN. 31 

ciated, sometimes atrophic. They appear to be constipated 
because of lack of food, and not infrequently this apparent 
constipation is soon relieved by a sufficient amount of nutri- 
ment. Constipation resulting from a superabundance of starch 
in the food is easily cured by the withdrawal of the injurious 
substance. 

Constipation produced by too much casein in the food will 
be relieved by diminishing its quantity. The proportion of 
casein in the food of infants should never be more than one 
per cent. Besides, this amount of casein ought to be copiously 
mixed with a glutinous decoction (oatmeal). 

Infants that have been fed on starchy food, or even such 
cereals as barley, should have oatmeal substituted for it. 

Constipation depending on lack of sugar is very often 
speedily relieved by increasing the quantity of sugar in the 
food. This is the case not only in artificial feeding, but also 
when the children are fed normally on breast-milk. Such 
mother's milk as is white and dense, and contains a large 
amount of casein, is made more digestible, and will produce 
better evacuations, when a piece of loaf-sugar dissolved in 
tepid water, or oatmeal-water, is given previously to every 
nursing. Older children will take honey to advantage, as 
long as it does not add to the abnormal gastric acids. Reg- 
ular doses of cod-liver oil, given twice or three times daily, 
will obviate or relieve constipation, besides fulfilling other 
indications. But it is self-understood that it must be pure, 
and not adulterated by the fashionable admixture of phosphate 
of calcium. Children of more advanced age, and with good 
gastric digestion, will be benefited by breads containing husk. 
Children of any age will be benefited by drinking large quan- 
tities of water. 

Rhachitis is frequently the result of protracted intestinal 
disorders. Therefore proper feeding is an absolute necessity. 
Animal food must predominate, but meat ought to be lean. 



32 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

The so-called erethic disposition requires less meat, but more 
of the better class of farinaceous foods, — viz., barley and oat- 
meal, with boiled milk, and salt. The same indications are 
valid for all the conditions subsumed under the head of scrof- 
ula. Coarse bread, acidulated food, fruit not absolutely ripe, 
must be avoided.* The introduction of phosphates, in what- 
ever shape, is a mistake, for the following reasons : 

In the careful experiments of Foster, who fed infants on 
milk, it was found that the mineral constituents were absorbed 
least (still less than fat). Of the ashes of milk in general, 
there were in the faeces 36.5 per cent.; of the calcium in par- 
ticular, seventy-five per cent. In spite of that the baby throve, 
and increased in weight in one week one hundred and seventy 
grammes. Thus there appears to be but very little need of 
salts on the part of the growing baby. The infant of two and 
a half years receives in one day 1.25 grammes of calcium, of 
which there is an elimination of 0.92 gramme in the faeces and 
0.03 in the urine. There is then a balance of 0.3 gramme in 
a day, of 2.1 in a week, of a kilogramme, or two pounds of 
calcium, in a year. This is all that is utilized. 

Almost the entire quantity of calcium in the body is depos- 
ited in the bones, which contain eleven per cent, of calcium in 
the adult, and in the infant and child somewhat less. 

There are some very important practical points connected 
with the results of these observations. 

As long as the food contains plenty of calcium and phos- 
phoric acid there is certainly no indication for the introduc- 
tion of the same in the form of medicine, or as an addition to 
food, for the purpose of improving nutrition. Thus the com- 
bination of cod-liver oil with phosphate of lime, which has become 



* Loose bowels behave well under the influence of acorn coffee (contain- 
ing gallic acid), or acorn cocoa, as introduced into practice by Michaelis, 
of Berlin. 



FEEDING OF SICK CHILDREN. 33 

so fashionable, is based upon an illusion concerning its alleged 
efficiency. Besides, the empirical observation has been made 
also, at a very early time, that immediately after the adminis- 
tration of preparations of calcium there was increased elimina- 
tion through both the faeces and the urine. 

Thus, as there is no actual absence of calcium phosphate in 
the food, the organism should be spared useless labor. In 
occasional cases, where the effect appears to be favorable, this 
very effect is different from what was intended. When rha- 
chitical or anaemic infants are supplied with phosphate of lime, 
and iron, bismuth, etc., they are generally patients who are suf- 
fering from primary or secondary catarrh of the stomach, with 
superabundance of acid in its secretion. In these very cases 
the calcium phosphate acts as an antacid, inasmuch as phos- 
phoric acid becomes free and the lime neutralizes the acids of 
the digestive organs. 

Fever consumes nitrogen (elimination of urea), carbon, 
water, and also salts. These losses must be repaired, but with 
great care. For fever diminishes at the same time the secre- 
tion of saliva, and of gastric, probably also that of the pan- 
creatic juice. Besides, it renders the stomach hypersesthetic 
(nausea, vomiting), and impairs the absorbing power of all the 
mucous membranes. In the capillary bronchitis of the nurs- 
ling, cow's milk is not digested satisfactorily. Still, nurslings 
will digest fairly sometimes, and lose less flesh in many of their 
febrile ailments than older children. A fair amount of pep- 
tones is absorbed both in the stomach and rectum. In mod- 
erate fevers some sugar is absorbed, also albumin ; fat in but 
small quantities, because of its tendency to become acid ; starch 
finds its saliva more or less diminished ; thus its amount must 
be carefully estimated. 

Food, when given in an undue quantity, may act injuriously 
by acting as a mechanical irritation, and by giving rise to fer- 
mentation. Can it thus increase the fever? Undoubtedly. I 

3 



34 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

have but lately seen a child sick with pain and fever who re- 
covered rapidly through the effect of a purgative, which brought 
away large masses of faeces. Another had what appeared to be 
a second relapse of typhoid fever, with a renewal of splenic 
tumefaction. All the symptoms vanished speedily when the 
bowels were thoroughly emptied of large offensive stools. 

In ordinary fevers the food must be liquid, and rather cool, 
in vomiting cold, in respiratory diseases warm, in collapse hot. 
The best feeding-time is the remission; in intermittent fevers 
nothing must be given during the attack except water, or 
acidulated water; in septic fevers nothing during a chill. 
Common ephemeral catarrhal fevers may do without food 
(except water) for a reasonable time. Sleep must not be dis- 
turbed, except in conditions of sepsis and depressed brain 
action. In both there is no sound sleep, but sopor, which 
may be interrupted. In sepsis (diphtheria and other) this 
rousing from sopor is an absolute necessity. Unless they are 
roused frequently to be fed sufficiently, and stimulated freely, 
the patients will die. Besides, in most of the cases, the tem- 
peratures are not high, and there is no contraindication to 
feeding on that account. 

Chronic inflammatory fevers bear and require feeding as 
generous as it must be careful. Altogether, however, it re- 
quires the good judgment of a well-informed physician to take 
into account the possible influences of individual habits, and 
energies, of ages and sexes, of constitutions, and of climate and 
season. 

Typhoid fever is of long duration, its temperature is 
sometimes quite high in children, as it is in adults. The small 
intestines are affected principally. Thus, not only is, after the 
first few days, a considerable amount of food required, but it 
must be so chosen as to be digestible in the stomach ; its proper 
selection is the more important the more the latter organ is im- 
paired by high temperatures. Beside plenty of water, or acid- 



FEEDING OF SICK CHILDREN. 35 

ulated water (hydrochloric, no organic, acid), albuminoids are 
indicated. Milk and cereals (in decoctions, which must be 
strained) are the proper foods. The administration of stimu- 
lants, both as to quantity and to time, depends on the charac- 
ter of the individual case, and the power of resistance on the 
part of the patient, beside the condition of the heart. Where 
the latter becomes feeble at an early period, beside heart-stim- 
ulants (digitalis, spartein, caffein, camphor), alcoholic stimulants 
are required. Diarrhoea demands (beside opium, naphthalin) 
albumin, rice-water, arrow-root, mutton-broth. Hemorrhage 
forbids food in any shape for a time, the duration of which 
depends on the general condition of the patient. At no time 
during the disease, and during the first ten days of fully estab- 
lished convalescence, the food must ever be solid. No veg- 
etables must be allowed until three weeks have elapsed since 
the beginning of apyrexia. When the milk and cereal food 
become distasteful, a change in their preparation, as described 
above, will and must suffice. The large majority of relapses 
are due to a dereliction in the strict rules of feeding. 

The diet in other chronic or acute diseases is regulated by 
the general rules which have been laid down before. Thus, a 
few words may suffice. 

Hereditary syphilis contraindicates the employment of 
a wet-nurse. The infant's own mother may nurse it if she 
can. 

Cerebral diseases contraindicate alcohol, coffee, hot soups, 
and solid foods. Cerebro-spinal meningitis results in speedy 
loss of weight and strength, particularly through severe and 
protracted vomiting, and the greatly-impaired appetite. In 
these cases feeding must be insisted upon. The feeding-cup, 
Soltmann's biberon pompe, and feeding through the nose (no 
tube into the oesophagus) must be resorted to. 

Eespiratory diseases require liquid food. Jurgensen's 
recommendation of roast, and bread with butter, is objection- 



36 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

able in every acute inflammatory case. Food and drink must 
not be too cold. Sugar, and sweets in general, are permissible 
in small quantities only. Farinaceous foods are the most re- 
liable ones. In the beginning no alcoholic stimulants. They 
will be required when debility and collapse set in at an early 
time, or in protracted cases. Capillar}'- bronchitis is often com- 
plicated with gastro-enteritis, and then no milk can be allowed • 
sometimes not even breast-milk is digested. 

Acute renal, diseases contraindicate alcohol in any 
shape, particularly beer ; also spices, coffee, and tea. Chronic 
renal diseases require generous feeding, because of the co- 
pious loss of albumin. But — contrary to Oertel and Loewen- 
mayer — no eggs or meats ought to be given in any quantity, 
or at an early period. Milk and farinacea must take their 
places. Alcohol is permissible in urgent cases only. Salt 
must be avoided except when the secretion of urine is to be 
fostered. It ought not to be forgotten that appetite and di- 
gestion may be suffering from the fact that the tissue of the 
stomach is cedematous, like all the rest of the organs. This 
is another reason why eggs and meats ought to be avoided. 
If required, in the later stages, peptones may take their place. 

Acute rheumatism requires milk diet and vegetable acids 
(lemonade), as long and at such times as they do not interfere 
with the milk food. 

RECTAL ALIMENTATION. 

The rectum absorbs, but it does not digest. Whatever, 
therefore, is to enter the circulation through the lower end of 
the alimentary canal must be dissolved before being injected. 
Suspension alone does not usually suffice. Water can be intro- 
duced in quantities of from twenty-five to one hundred grammes 
(one to three ounces) every one, two, or three hours, and may 
thus save life by adding to the contents of the thirsty lymph- 
ducts and empty blood-vessels. Salts in a mild solution will 



FEEDING OF SICK CHILDREN. 37 

thus be absorbed. Food must be more or less peptonized before 
being injected. The peptones mentioned above are readily 
absorbed when fairly diluted. When too thick they are not ab- 
sorbed, become putrid, and a source of irritation. Milk ought 
to be peptonized. The white of eggs becomes absorbable 
through the addition of some chloride of sodium. Kussmaul 
beats two or three eggs with water, keeps the mixture through 
twelve hours, and injects it with some starch decoction. The 
latter is partly changed into dextrin. Fat, when mixed with 
alcohol, becomes apt to be partly absorbed. Andrew H. 
Smith recommends the injection of blood. Its soluble albu- 
min, salts, and water are readily absorbed ; more we ought 
not to expect. Still, he has observed that the evacuations of 
the next day contained none of the injected blood. Whatever 
we do, however, and be the rectum ever so tolerant, not more 
than one-fourth part of the food required for sustaining life 
can be obtained by rectal injections, and inanition will follow, 
though it be greatly delayed. Finally, children are not so 
favorably situated in regard to nutritious enemata as adults. 
In these the lengthening of the nozzle of the syringe by means 
of an elastic catheter permits of the introduction of a large 
quantity of liquid ; indeed, a pint can be injected, and will be 
retained. But the great normal length of the sigmoid flexure 
in the infant and child, which results in its being bent upon 
itself, prevents the introduction of an instrument to a con- 
siderable height. It will bend upon itself; besides, a large 
amount of contents will be expelled by the feeble or resisting 
young patient.* When a solid instrument is used, it is apt to 
be felt high up in the abdomen. This is the result of a large 
portion of the intestine being pushed upwards with the tube. 

* The amount can be somewhat increased by raising the baby by its 
feet, while the chest and abdomen are supported by a soft pillow, and in- 
jecting quite slowly, or, rather, allowing the liquid to flow in from above 
downwards. Gentle manipulation of the abdomen, while the procedure 
is going on, will aid our purpose. 



38 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

II. 

TREATMENT OF THE NEWLY-BORN. 

1. Asphyxia. 

The prognosis of asphyxia and of its treatment is a very 
doubtful one in many cases. It does not only depend on the 
knowledge and skill of the physician, but on the causes of the 
abnormal condition. A moderate or serious compression of the 
head, compression or prolapsus of the cord, intra-uterine respi- 
ration and aspiration of foreign bodies, apoplexy, ansemia of 
the foetus, accumulation of carbonic acid in the blood, poison- 
ing by the morphia, chloral, or excessive temperature of the 
mother, congenital diseases, and malformations, each of them or 
several combined, influence both the prognosis of the indi- 
vidual case and the result of therapeutical procedures. 

When the long duration of labor, the prolapsus of the cord, 
the protracted compression of the head, the early loss of amni- 
otic liquor, or a high temperature of the mother endangers the 
life of the foetus, the best preventive of asphyxia is the arti- 
ficial termination of parturition. The respiratory organs of 
the foetus passing out of the vagina must be protected from 
contact with copious discharges of liquor amnii and other 
foreign material accumulated in the bed, the face being raised 
so that aspiration, mostly through the nose, cannot take place. 
The mouth of the newly-born, unless it cries lustily, must be 
cleansed immediately by a moistened piece of cloth wrapped 
round the finger, the tongue drawn forward, and the baby 
placed on its side before attention is paid to anything else. 
Beating the nates, tickling of the fauces by means of a feather, 
and the momentary inhalation of ammonia can be resorted to 
before the baby is separated from the placenta. Most practi- 
tioners, indeed, will prefer to prolong the connection with the 



TREATMENT OF THE NEWLY-BORN. 39 

maternal organ until the pulsation of the cord begins to flag, 
under the usual circumstances. The separation of the baby 
must take place immediately when there is no pulsation in the 
cord, or asphyxia is well pronounced. When the baby is 
strong and cyanosis marked, Grenser recommended to allow 
the cord to bleed before the application of the ligature. When 
bleeding was but scanty, he invited it by placing the baby in 
a warm bath. This procedure I have imitated several times 
with advantage. 

When the ligature has been applied and the baby removed, 
the mouth of the asphyctic infant ought to be cleansed again 
as above, quickly but gently. For amniotic liquor, meconium, 
and vaginal secretion, when aspirated, will, though the as- 
phyctic condition may be relieved, give rise to bronchitis and 
pneumonia after two or four days. Many babies die in this 
way. 

Insufflation into the lungs for the purpose of establishing 
respiration has been practised by Smellie as early as 1762. It 
is done from mouth to mouth, from mouth to nose, or by 
catheterization of the larynx. The first method is not reliable, 
if but for the tongue closing pharynx and larynx ; the second 
is often successful, but may inflate the stomach as well as the 
lungs. By inflating the former the chances for a normal 
action of the lungs become less. After every insufflation 
which fills the lungs, the chest ought to be compressed by two 
hands over the lower latero-anterior region of the chest-walls. 

The direct insufflation of the lungs may become detrimental 
for several reasons. Thus, H. Reich has the case of a con- 
sumptive midwife who was reported to have infected twelve 
infants with acute tuberculosis in thirteen months. In the 
practice of another midwife, who was healthy, in the same 
town, no such case occurred. During nine previous years 
there were but two cases of tubercular meningitis, and but one 
in the year following the death of the consumptive woman. 



40 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

Moreover, the act of insufflation may prove dangerous by the 
impossibility of limiting the force of the entering volume of 
gas. Rupture of pulmonary tissue and emphysema have been 
observed. The same accident may occur when a catheter is 
used for the same purpose. It has, however, the advantage of 
permitting the sucking out of the aspirated material before air 
is blown into the lungs. Ribemont's and others' metal cathe- 
ters cannot be carried much below the vocal cords. An elastic 
catheter, guided by a wire which allows any degree of bending 
and may be withdrawn when the vocal cords have been passed, 
is better adapted for both aspiration and inflation. 

The asphyctic baby ought to be plunged into a warm bath 
(100° F.) immediately, and gently rubbed. The other methods 
may be continued during that time, — beating, tickling, elec- 
tricity. When it is thin, pale, and collapsed, a hot injection 
into the bowels (104°-108°) will render good service. The 
quick and repeated alternation between the warm bath of a 
minute and a cold one of one or two seconds, or the pouring 
of cold water on chest, or neck, while the body is in the warm 
bath, restore many. But great care must be taken lest the 
bath be too hot. It may produce convulsions, and has been 
known to give rise to tetanus. Before, and after the bath, in- 
deed at any time, the vigorous swinging of the baby on the 
arms of the medical man is a good adjuvant. 

Among all the mechanical methods of artificial respiration 
(Marshall Hall, Silvester, Howard, B. Schultze, Pacini, 
Woihler, Bani, Schtiller) those of Silvester and Schultze 
render the best services in the asphyxia of the newly-born. 
Both are very simple, and either of them is effective. 

Silvester places the patient on his back, a small pillow (piece 
of clothing, towel, sheet) between the shoulders, the tongue 
drawn forward. The two arms are caught above the elbow 
and slowly carried upwards. Thus the chest is expanded. 
Then they are carried downwards and pressed against the sides 



TREATMENT OF THE NEWLY-BORN. 41 

of the chest, a little anterior to the axillary line. Thus the 
lungs are compressed. This combined action may be repeated 
fifteen or twenty times in a minute. 

B. Schultze places his index fingers into the axillae, the 
three other fingers gently against the sides of the chest, the 
thumbs covering the shoulder from behind. The infant is 
then swung forward. The lower extremities bend on the ab- 
domen, the abdomen presses against the diaphragm, and the 
lungs are compressed, — expiration. The parts then return 
slowly downwards and swing back, thus expanding the chest, 
— inspiration. This action may also be repeated fifteen or 
twenty times in a minute. There is but one (occasional) con- 
traindication to the employment of this method, — viz., the 
insufficient development of the foetal bones. When the newly- 
born is too premature, and the ribs too soft and flexible, it is 
useless. 

During all this time, whenever feasible, the surface of the 
infant must be kept warm artificially by hot blankets, stones, 
bottles, and a few drops of brandy, whiskey, camphor- water, 
or tincture of musk may be given in some hot water if deg- 
lutition is possible, or injected into the rectum. When the 
main difficulty appears to be, after a while, in the excessive 
debility of the heart, it is possible that a five-hundredth part 
of a grain of nitroglycerin, repeated after fifteen and thirty 
minutes, will do good and speedy service through its ready 
absorbability on every mucous membrane. I have no experi- 
ence with it in the asphyxia of the newly-born, but its rapid 
action in failing heart and collapse and shock from other 
causes encourages me to recommend it for a fair trial of its 
powers. 

Electricity was recommended in cases of asphyxia as early 
as 1793 byHufeland. But the first case, in which the rhyth- 
mic faradization of the phrenic nerve and its associates was 
resorted to (Ziemssen) for the purpose of producing artificial 



42 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

respiration, was that of an asphyctic girl poisoned by carbon 
oxydul. The phrenic nerve acts on the diaphragm. Its aids 
are the cervical plexus, which controls the trapezius, levator 
scapula?, and middle scalenus muscles, and the brachial plexus. 
The ramifications of the latter are the anterior thoracic nerve 
for the pectoralis major and minor ; the posterior thoracic 
for the middle scalenus, posterior superior serratus, and the 
rhomboid muscles; and the lateral thoracic for the serratus 
anticus major. 

In many cases since, such as poisoning by chloroform, coal 
gas, opium, diphtheria, sulphide of hydrogen, and pernicious 
intermittent fever, also in those of apoplexy, drowning, and 
hanging, electricity has been employed to advantage. Its eifect 
is often rapid and powerful. 

In asphyxia of the newly-born, the systematic faradization 
of the phrenic nerve has been first employed by Lauth and 
Pernice. 

The point of application selected by most authors is near the 
sterno-cleido-mastoid muscle, over the phrenic nerve. The 
other pole is applied either to the neck or to the diaphrag- 
matic region or any other part of the surface. The localiza- 
tion of the effect to the phrenic nerve alone, which was in- 
sisted upon by many, is certainly an illusion. The current 
will surely strike the pneumogastric, phrenic, sympathetic, and 
many sensitive and motory nerves at the same time. As this 
cannot be avoided, as indeed it is better that it should be ex- 
actly so, it is best to use large sponge electrodes and moisten 
them thoroughly with salt water. The head, arms, and shoul- 
ders should be slightly raised, and a small pillow placed be- 
tween the shoulders for the asphyctic baby to rest on. One 
of the electrodes must be kept stationary ; the other brought 
into contact with the surface but a single moment. A deep 
inspiration will then take place, the lungs will expand, and 
lateral pressure on the lower part of the chest must be resorted 



TREATMENT OF THE NEWLY-BORN. 43 

to for the purpose of emptying the lungs afterwards. An- 
other application is then made with the same result, and must 
be followed with the same manipulation. This has to be con- 
tinued for some time until the baby cries, and it appears safe 
to discontinue the application. Whenever a cough or a cough- 
ing movement is noticed, it must be omitted temporarily. The 
favorable result, however, is not always permanent. The 
causes of the asphyctic conditions are still active, and the infant 
will require resuscitation again, and perhaps many times. Thus 
close attention must be paid, sometimes for many hours. 

Great care must be taken in regard to the duration of the ap- 
plication. Continued or too frequent irritation by the current 
causes over-irritation and paralysis. Not infrequently is the 
immediate effect a favorable one, inspiration becoming deep and 
the heart active, but after but a short time the former grows 
more superficial, the pulse feeble, and the cyanotic hue re- 
turns to the lips and finger-nails. Then it is time to stop for 
a while, and resort temporarily to other means of resuscitation. 
Thus the practice of Lauth's, who applied the current for from 
two to three minutes, is decidedly improper and dangerous. 

In some cases, where the interrupted current is inefficient, 
the galvanic (continuous) current, with occasional interruptions, 
has been known to yield better results. In my own cases I 
have never had an opportunity or been under the necessity of 
employing it. 

The application of large sponge electrodes may not always 
be convenient. In those cases no harm is done by using the 
metal poles instead. Though the irritability of the brain 
(and nerves) is but low in the newly-born, the pain produced 
by the interrupted current thus applied is very intense, and 
the effect on the contraction of the diaphragm quite marked. 
Thus it is not necessary to lose time for preparing, if not handy, 
the more complicated apparatus. Still, exhaustion is more 
readily obtained through resuscitating by pain and muscular 



44 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

action combined than by muscular contraction alone. In most 
cases, however, I was satisfied with not losing even a fraction 
of a minute, particularly in those early times, where the most 
convenient apparatus was the old-fashioned rotating machine. 
How long is the asphyctic baby to be watched and the at- 
tempts at resuscitation to be renewed ? At all events they 
must not be given up as long as the heart-beats are audible, 
though ever so feebly. Nor is the crying sufficient to permit 
watchfulness to be relaxed. The deep recession, during in- 
spiration, of the diaphragmatic region (the " peri pulmonary 
groove" of Trousseau) must have ceased, the cry be vigorous, 
the eyes wide awake, and the extremities in lively motion. 
Before this end is attained there is danger of a relapse, partly 
from impaired innervation and the continuation of some of 
the causes of the asphyxia, and partly from obstruction through 
mucus, which may be coming up constantly and gathering in 
the pharynx and posterior nares. 

2. Post- Natal Asphyxia and Atelectasis. 

Atelectasis may be congenital or acquired. The lungs may 
never have expanded to their normal degree, or after expan- 
sion had taken place, they may have collapsed, or contracted 
again. The causes of this condition may also be either con- 
genital or acquired. There may be malformations and intra- 
uterine diseases of the organs of respiration or circulation, such 
as defective development of the lungs, hernia of the diaphragm, 
hypertrophy of the thyroid gland, pleural effusions, syphiloma 
of the lungs, acquired bronchial catarrh, bronchitis, and pneu- 
monia. Or anomalies of the nervous system may exist, such 
as hemorrhage or some other injury of the respiratory centre, 
and cerebral pressure from effusion, beside intra-uterine mal- 
formations. Or, finally, the baby may be premature, with 
feeble muscles and soft bones. 

The treatment resembles much, or is identical with, that of 



TREATMENT OF THE NEWLY-BORN. 45 

genuine asphyxia. Respiration must be insisted upon. Warm 
and cold baths, cold affusions in the warm bath, swinging, 
beating, and electricity come each in for their share in the 
treatment. The baby must be made to cry, or it will perish. 
This indication is particularly urgent in the acquired cases 
of atelectasis which result from bronchitis. There the small 
bronchial tubes are filled with a viscid sticky mucus, which 
must be removed. This is a condition not peculiar to the quite 
young, it is as well met with in older babies suffering from 
bronchitis, particularly when in a condition of ill-nutrition and 
general debility. In them, the closing of the nose and mouth 
for from four to eight seconds will so saturate the respiratory 
centre with carbonic acid as to elicit deep and forcible inspira- 
tion immediately. It is an effective method, and not cruel 
because it is successful. 

The babies must be fed conscientiously. As many are suf- 
fering from inanition, this must not be neglected. They must 
have plenty of water, warm or hot, with from one to four 
drachms of brandy through the twenty-four hours, aq. cam- 
phorse, a few drachms; perhaps, as suggested above, nitro- 
glycerin. Hot injections into the rectum will stimulate the 
nerves and fill the blood-vessels. The infant must be carried 
about, its position in bed changed from time to time, and its 
skin be kept warm according to the methods detailed before.* 
Even the most desperate-looking cases, with shallow respira- 
tion, and cyanosis of the skin and mucous membranes, may 
recover when the attendants are as persistent as the morbid 
condition dangerous. 

* It is this condition, in which Crede's and Tarnier's apparatuses (cou- 
veuse) have triumphed over great difficulties, and mainly in premature 
babies. Still, any box or bed, with hot bottles and stones, or a box with 
double walls filled in with hot sand, or a bed with hot flannel, or cotton, 
or the hot register, or anything the good will and ingenuity of the 
practitioner will supply, will answer the purpose. At the same time the 
air admitted to the lungs must be cool and pure. 



46 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

D'Outrepont saved a newly-born of thirteen inches in 
length and one and a half pounds in weight, Kopp one of 
eleven inches and two pounds, Redman one of thirteen inches 
and a pound and three and a half ounces, Ahlfeld one that 
was born in the twenty-ninth week of utero-gestation, measured 
fifteen inches (thirty-nine and a half centimetres), and learned 
how to suck after a few weeks ; and another one that had the 
same size of fifteen inches and a weight of forty-eight ounces 
(fourteen hundred and fifty grammes) when five weeks old. 
It also took the breast afterwards. Several infants of less than 
three pounds at birth I have saved myself, nor are similar 
cases quite rare in the literature of the subject. 

J. H. Moore published in the Philadelphia Reporter of April 
17, 1880, the case of a foetus born before the end of the sixth 
month of utero-gestation ; length nine inches, weight one and 
a half pounds, that cried after thirty minutes, but did not 
move. Fifteen months afterwards the same foetus is said to 
have commenced to walk, and weighed nineteen pounds. 

3. Kephalhcematoma. 

The hemorrhage between (mostly) the parietal bone and its 
pericranium is usually the result of pressure by the lower 
segment of the uterus. Occasionally, however, kephalhaema- 
toma is observed after breech presentation also. It is caused 
by the deficient development of the external layer of the 
cranial bones and the shallowness of the indentations in which 
the blood-vessels are running, the thinness of the vessels, and 
the mobility of the integument. It is circumscribed, does not 
spread beyond a suture, fluctuates, and begins to be sur- 
rounded, after a few days, by an osseous ring, the result of the 
formation of new bone from the raised periosteum. It grows 
in size for some days, then remains stationary, and is gradually 
absorbed within from six to twenty weeks. After this time 
the bone is thickened, but absorption of the newly-formed 



TREATMENT OF THE NEWLY-BORN. 47 

bones will also take place in most cases. But rarely a perma- 
nent thickening will be noticed in later life. 

In some cases there is an internal kephalhsematoma as well. 
It consists in a hemorrhage between dura mater and cranium, 
and may lead to all the consequences of intra-cranial hemor- 
rhage (apoplexy of the new-born), — viz., convulsions, paralysis, 
death, or meningitis, cystic degeneration, etc. There may be 
no contiguity between the external and the internal hseinatoma. 
Still, many cases of the external form will extend directly into 
the cranial cavity through a congenital fissure in the bone. 

The treatment is forestalled by what has been said of the 
spontaneous absorption of the extravasation. No treatment is 
required. The swelling must be left alone. The bony thick- 
ening will also get well in the course of time. It is impor- 
tant to insist upon this expectative treatment, because the 
attendants will often not appreciate the absolutely benign 
nature of the large tumor. 

Meddlesome practitioners have tried compression. If there 
be any communication with the cranial cavity, this procedure 
may become dangerous by blood being pressed into the interior. 
Ointments have been recommended " to make believe," for the 
purpose of quieting the anxiety of the family. Puncture has 
been resorted to. If made at an early period, it will facilitate 
new bleeding; in many a case it has been known to produce 
suppuration, though the operation was believed to have been 
made antiseptically. Incision is still more reprehensible. It 
is not permissible except in those cases which have terminated 
in suppuration through previous maltreatment. Then a large 
incision and thorough disinfection are indicated, and will be 
followed by a relief to pain, redness, and fever. Puncture, 
aspiration, or incision may perhaps be necessary, even without 
suppuration, in one of two conditions : firstly, the tumor may 
be so large as not to undergo absorption for many weeks, and 
to endanger the bone, which may become necrotic; still, I have 



48 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

not seen such a case these twenty years ; secondly, in a case of 
complication with apoplexy, aspiration may be capable of 
allowing some of the internal extravasation to escape. 

Other indications for the treatment of this internal kephal- 
hsematoma are yielded by the asphyxia depending upon the 
disturbed innervation. The antiphlogistic treatment will be 
confined to cold or cool applications only. The consecutive 
paralysis demands an appropriate treatment, the results of 
which will be mostly questionable, and depend upon the 
amount of extravasated blood, of tissue destroyed or com- 
pressed, and consecutive changes in the nerve-centre. 

4. Hcematoma of the Sterno-Cleido-Mastoid Muscle. 

The fragility of the foetal blood-vessels and some injury 
experienced by the muscle during parturition gives rise to a 
hemorrhage about or above the middle of the long muscle. 
When observed the tumor has the size of a hazel-nut or more; 
it is spherical, circumscribed, and rather hard. The latter 
condition is due to the secondary inflammation of the torn 
muscular fibres. This occurrence is not at all very uncommon. 
Even in older children, mainly in kite-flying boys, who extend 
either of their sterno-cleido-mastoid muscles incautiously, the 
same hsematoma and myositis are observed. 

When observed at an early period the local application of ice 
may reduce the bleeding. For a week, after ceasing the employ- 
ment of ice, small pieces of cloth moistened with cold water 
will check the secondary inflammation to a certain extent. 
During all this time the head must be kept quiet, — best per- 
haps by carrying the baby on a hair pillow large enough to 
support the whole body, head included. When the tumor has 
time to become hard, it may last for years; .when it is large, 
it may give rise to a slight torticollis. Then gentle stretching 
and massage, the application of a mild galvanic current, and 
the inunction of an absorbable ointment of iodide of potas- 



TREATMENT OF THE NEWLY-BORN. 49 

sium may be tried to advantage (iodid. potass., aq., aa 1 ; adip. 
suill., 2 ; lanolin, 6-8). 

5. Sclerema. 

The induration of the connective tissue of the newly-born 
known by that name, consists of a serous infiltration (of and) 
under the skin, begins generally in the lower extremities, and 
spreads over the whole body with the exception of the chest. 
The surface is apt to be slightly hypersemic in the begin- 
ning, and then turns yellowish and quite pale. Respira- 
tion is shallow, nursing feeble, secretion of meconium and 
urine scanty, sensibility diminished, the pulse slow (60-75), 
accelerated only towards the fatal end, and temperature re- 
duced much below the normal, even to 90° and less. Re- 
covery takes place but very rarely. Even those who suffered 
from a slight attack only, are liable to perish of pneumonia 
after two or three weeks. Many of the infants are prema- 
turely born, exhibit defective innervation, possibly from foetal 
brain-disease, or suffer from some cardiac affection. 

The patient must be fed from a spoon or through the 
" biberon pompe," mentioned in the first essay of this series. 
Alcoholic stimulants may be given in the shape of brandy 
or whiskey, four to six drops every half-hour ; also a drop 
of tinct. digitalis every hour or two hours, and aq. camphorse, 
ten drops every hour. Massage commencing at the periphery, 
gentle but persistent with the thoroughly-warmed hand, or 
through a warmed cloth, will improve the circulation, and 
probably absorption, to a certain extent. Maybe, also, that 
extensive (general) galvanization of the surface will serve the 
same purpose. The infant must be kept warm near a stove 
or furnace register, provided the head can be kept away from 
it and the air-supply for the lungs be kept up at a moderate 
temperature. Otherwise hot stones, hot sand, hot bottles, must 
be distributed, well covered, through the bed at a safe dis- 

4 



50 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

tance. Frequent bathing in salt water of at least 100°, with 
constant friction and massage in the bath, will prove as bene- 
ficial as the bad or very doubtful prognosis in most cases will 
permit. 

6. Bathing. 

The first bath of the newly-born, and bathing of infants 
in general, demands great caution. For the temperature of 
the young exhibits some peculiarities in regard to both its 
development and elimination. Immediately after birth it is 
apt to decrease by a degree (F.) or more, in consequence of 
defective circulation and respiration and the great difference 
of the baby's surroundings before and after birth. A feeble 
new-born requires more time for its temperature to rise again 
to its norm. That is so particularly in regard to the surface. 
Thus it is that the thermometric measurements when made in 
the axilla are as deceptive in the feeble young as they are apt 
to be in adults, with an immense fat layer underneath or with 
insufficient superficial circulation. 

A certain degree of cooling in the air of the room takes 
place under all circumstances at birth. When moderate, the 
sudden change acts favorably by inciting reflex action, but a 
considerable and continued reduction of temperature must 
have a dangerous influence at a time when the functions of 
the body are not yet regulated. 

In Lassar's experiments, when an animal after recovering 
from albuminuria got exposed to a cold temperature, the same 
condition returned. Rabbits thus exposed, without or after 
depilation, suffered from interstitial inflammations of liver, 
lungs, heart, and neuroglia. The blood-vessels of liver and 
lungs became enormously dilated, the arteries filled with 
thrombotic masses, and leucocyte emigration was marked round 
the veins. When the animal was pregnant, even the liver and 
other organs of the foetus were found to be inflamed. This 



TREATMENT OF THE NEWLY-BORN. 51 

is exactly what clinical experience has taught every observer 
of every generation, in spite of modern contradiction. Thus 
I have observed a sudden return of the morbid symptoms 
in three persistent and protracted cases of hsemoglobinuria 
after every exposure to cold, and particularly cold and moist 
air. 

Therefore the newly-born babe must not remain uncovered 
for any length of time. The nurses who spend — with more 
pedantry, emphasis, and self-consciousness than intelligence — 
much unnecessary time in oiling and soaping and washing 
and bathing, turning this and that way, drying the surface, 
wrapping the navel, applying the bandage, and dressing the 
newly-born in fineries, in which it finally arrives shivering 
with a cold nose and blue feet, are not infrequently the causes 
of ill health or death. In a case recently seen, the pneumonia 
of the newly-born was undoubtedly due to the fact that the 
baby was neglected while both physician and nurse were en- 
gaged about the fainting mother. Craig must have seen 
many such cases, for with him "no baby is ever washed, 
dressed, fed, tied up, the cord is not wrapped up, but the in- 
fant is anointed with fat and wrapped in flannel the first 
twenty-four or thirty-six hours." 

The bath of the newly-born must not be hot. A single 
midwife in Elbing lost ninety-nine babies out of three hun- 
dred and eighty, of trismus. Through all her life she had 
estimated the temperature of the bath by trying it with her 
uncovered arm. She lost her temperature sense after a while, 
as was found by a judicial investigation, and the babies their 
lives. Still, the bath ought not to be less than 90° F., nor 
ought it to be much cooler through a number of months, in 
spite of a French author's opinion, who says that the epi- 
dermis becomes macerated by warm baths; that babies who 
are getting bathed grow " pale, soft, and flabby and eczema- 
tous," and proves the correctness of his position by his zoo- 



52 THERAPEUTICS OP INFANCY AND CHILDHOOD. 

logical discovery that " no other mammalia take a warm bath 
regularly."* 

The proportion of the surface to the cubic mass of the 
human body is larger in an infant than in an adult, and with 
it is the number of peripherous nerve-ends and capillaries 
relatively greater. Thus there is a greater liability to re- 
flex symptoms depending on exposure in spite of the low 
degree of nervous irritability in the newly-born. Thus it is 
that a protracted cold bath is not well tolerated even by older 
infants; but, also, that tepid or cold bathing or packing ex- 
hibit a very much more rapid effect in the young than in the 
old. For both the reduction of temperature and the reflex 
effect do not depend on the weight of the body, but the ex- 
tent of the conducting and radiating surface. 

When the baby is six months old, particularly during the 
summer months, the warm bath is to be succeeded by washing 
and friction with tepid and, later on, cold water. When 
washing is substituted for bathing, water may be selected of 
a lower temperature, inasmuch as but a part of the surface 
is exposed to its influence at one time. When the bath is 
gradually made cooler, in the course of time, friction of the 
skin during bathing stimulates its action. In pathological 
conditions, when cool or cold bathing is resorted to for the 
purpose of reducing an abnormal temperature, this aim is 
always reached as far as the surface is concerned. But to 
accomplish the same end for the whole body, it is necessary 
that the skin should retain its vitality and lively circulation. 

* To the general rule implied in the above remarks on the necessity of 
bathing in warm water only, according to which the body of the newly- 
born infant is to be kept warm, the head forms an exception. Artificial 
heat and feather pillows ought to be avoided. A soft hair pillow is pref- 
erable, or a quilt lined with a layer of cotton. Whenever it is necessary 
to employ a soft head-rest, a feather pillow may be covered by a bed- 
sheet folded -up to the size of the pillow and fastened to its corners by 
safety-pins. 



TREATMENT OF THE NEWLY-BORN. 53 

Unless that be so, the internal temperature may remain un- 
changed, or even rise while the surface is cool. In such a 
case, which must be ascertained by taking the rectal tempera- 
ture, the cold bath ought to be followed immediately by a hot 
one for the purpose of restoring the surface circulation. In 
this way the reduction of temperature aimed at by the admin- 
istration of a cold bath is finally accomplished by the hot in 
a desperate case. In milder ones the warming of the extremi- 
ties and the general surface by dry heat may suffice to restore 
the warmth of the surface. At all events, a cool or cold bath 
after which the feet do not become warm at once, is dangerous. 

7. Mamma. Mastitis. Perimastitis. Angioma. 

Since the time of Menard, Scanzoni, and Guillot, the secre- 
tion of the mammary gland of the newly-born has been the 
subject of frequent investigations by clinicians, chemists, and 
physiologists.* It is mostly found towards the end of the first 
week, and resembles very much the milk of the mature 
woman, in the mammae both of the male and female infant. 
The superficial milk-ducts are obstructed with epithelium; 
the interior ones are dilated in many places and filled with a 
cuboid epithelium and a liquid which resembles colostrum. 
This secretion may be absent, but it is frequently found in 
premature or still-births, though the mammae be but rudi- 
mentary. The dilatations (ectasia?) will increase in size for 
weeks, and begin a retrograde development as late as the 
middle of the first year of life. 

The tendency of epithelial elimination, which is a peculiar 
feature in the newly-born, and which is so commonly observed 
in its skin, mucous membranes, sebaceous follicles, and kid- 
neys, appears to be very marked in the mamma of the newly- 

* Jacobi, in Gerhardt's Handb. d. Kinderkrankh., 1st vol., 2d part, p. 
39, of the 2d ed. 1882. 



54 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

born. This discovery of Epstein's renders the subject of our 
discussion very much clearer from an etiological point of view. 

The swelling and secretion of the gland may last a week or 
two when undisturbed. After it has been squeezed out ever 
so gently, a new secretion will be invited and continue five or 
six weeks. Thus pressure of any kind must be avoided. It 
is barely possible that it may not be injurious, and that a 
gentle inunction of warm oil, which is so commonly used, may 
do no harm. But as a rule every sort of pressure occasions 
an attack of inflammation and, maybe, suppuration. Though 
an abscess be ever so small it is sufficient to destroy all or a 
part of the mamma forever, — a serious misfortune in a female. 
A swelled mamma must be left alone. Applications of cool 
or warm water, the cloth being well pressed out and covered 
with oil-silk and cotton, or flannel, or of a mild lead wash, 
will answer well. Also applications of iodide of potassium 
dissolved in glycerin, one part of the former in two or five 
of the latter, which are repeated every few hours. Extract 
of belladonna may be added to advantage. When suppura- 
tion could not be avoided, the incision must not be delayed. 
It ought to be made at the greatest possible distance from the 
nipple, directed towards the nipple, so as not to cut the main 
milk-ducts, and treated antiseptically. Indurations remaining 
behind require frequent and gentle inunctions of an iodoform 
ointment (iodoform, 9ii; ol. bergamot, r^iv; adip. suilli, 
3vi-x), or iodoform collodium, to be applied with a brush 
twice every day (iodof., 1; collod., 10-20) in such a manner 
that only those scales of the application which are found peeled 
off from the skin, have to be removed before a new layer is 
applied over the dried-up previous application. A very mild 
galvanic current of from two to six elements, conducted through 
the induration by means of soft sponge electrodes moistened 
with salt water, has rendered me good services in many cases. 

Perimastitis, the inflammation of the surrounding connective 



TREATMENT OF THE NEWLY-BORN. 55 

tissue, may occur primarily, but is mostly the final result of 
traumatic mastitis. It grows dangerous, unless incisions are 
made early and treated antiseptically, with great care. I have 
met with not a few cases in which the suppuration of the con- 
nective tissue was very extensive, spread over a large surface, 
undermined the skin of the chest, axilla, and back, resulted in 
gangrene, erysipelas, or sepsis, and terminated fatally. The 
antiseptic solutions (applications, injections, irrigations) must 
be used frequently, but ought to be mild. Carbolic acid ought 
to be avoided, for infants are easily poisoned by it. 

The mamma ought to be examined for angiomata in every 
baby, whether there be mastitis or none. Nsevi are by no 
means rare in this neighborhood, and ought to be destroyed at 
once, either by the application of concentrated nitric acid or 
by the actual cautery (red-hot iron, galvano-cautery, or thermo- 
cautery), for they are liable to grow rapidly, and prove danger- 
ous to the female. The former mode of treatment is adapted 
to superficial nsevi only. Deep-seated ones, and real vascular 
tumors, require the actual cautery. 

8. Treatment of the Cord. 

The indications for the application of the ligature, and 
thereby the complete interruption of foetal circulation, appear 
to vary in the practice and teachings of the obstetricians. 
When the baby has cried a few times, the majority apply the 
ligature and cut the cord. Others insist upon waiting for the 
collapse of the cord produced by that of the vein, while the 
arteries are still pulsating, and some will wait for the disap- 
pearance of the arterial pulse. A few facts may be remem- 
bered for the purpose of guiding the practitioner in individual 
cases, for the amount of blood entering, or retained in, the 
body of the infant is by no means an indifferent matter. 

If the ligature be applied after the cessation of the umbili- 
cal pulsation, there are still six ounces of blood (one hundred 



56 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

and ninety-two grammes, according to Zweifel) in the placenta. 
If the latter be compressed by Crede's procedure that amount 
is reduced to three ounces (ninety-two grammes). Thus the 
difference between the two procedures means a difference of 
three ounces of blood in the circulation of the newly-born, 
which is an enormous addition to the usual quantity of blood, 
which in the infant but little older is but little more than five 
per cent, of the total weight of its body. After all, it appears 
that the deferred separation of the baby, when poorly devel- 
oped and pale, and the admission of more blood to its system, 
is deserving of recommendation ; while, on the other hand, 
there may be an occasional indication for bleeding the infant.* 

The introduction of a large quantity of blood is, however, 
no unmitigated blessing. The blood-vessels of the newly- 
born are so thin and fragile that spontaneous hemorrhages on 
serous membranes and into the nerve-centres, etc., are by no 
means uncommon under normal circumstances. It is true that 
the destruction of superfluous blood-corpuscles is very rapid, 
as rapid, indeed, as it is known to be after transfusion in the 
adult, but some time is required to accomplish that end, and 
during that time hemorrhages may take place, and have been 
reported by Neumann and Illing. This danger is sufficiently 
great to counterbalance the alleged observation of Hofmeier, 
according to whom babies, after deferred separation from the 
mother, lost less weight and commenced to increase sooner 
than those removed more speedily. However, Violet states 
that the former lost twenty ounces (six hundred and nineteen 
grammes), the latter but nineteen (five hundred and eighty- 
five grammes). 

Nor does Porak's observation, according to which congested 
babies exhibit a more intense degree of jaundice, lack con- 
firmation. 

* Archives of Pediatrics, March, p. 130. 



TREATMENT OF THE NEWLY-BORN. 57 

If the ligature be thin, it is liable to cut through the walls 
of the blood-vessels prematurely ; if too thick, it may not suf- 
fice to compress them satisfactorily. It ought to be applied at 
a distance of from one and a half to two and a half inches 
from the abdominal wall. Not nearer, in order to avoid the 
effect of the immense muscular power of the umbilical arteries 
inside the abdominal cavity. A second ligature is placed about 
an inch from the first, and the cord cut between them. It is a 
good rule, which must surely be adhered to in every case of 
thick cord, to apply an additional ligature between the first 
and the abdominal wall, to avoid hemorrhage from the insuf- 
ficiently compressed arteries, which may take place after the 
cord has commenced to shrink. The abdominal end of cord 
is then wrapped up in a dry and soft piece of linen, lint, or 
cotton, placed on the left side of the abdomen, and fastened, 
by means of a soft flannel bandage, which is wide enough to 
cover the larger part of the chest and all of the abdomen, so 
as not to slip. 

In wrapping up the end of the cord no oil must be used. 
Warmth and dryness favor m unification; moisture and ex- 
clusion of air, gangrene. This holds good also for the cord 
when it is separated from the living baby by an additional 
ligature, and in the dead. Thus, the former forensic axiom, 
that a dry cord proved life, which prevailed for decades after 
Meckel had demonstrated its fallacy as early as 1853, is ab- 
solutely worthless. Thus, fatty substances, and moisture of 
any kind, must be avoided as much as possible. Powdered 
subnitrate of bismuth, or oxide of zinc, or iodoform, or sali- 
cylic acid, one part with ten parts of starch, may be dusted 
round the insertion of the cord and over the stump daily. 
The latter application is not necessarily useless (from the 
point of view of antisepsis), for the separation of the cord is 
a gradual one, and not uniform through the whole thickness 
of the amnion and the three blood-vessels. 



58 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

The size of the sore stump and the rapidity or slowness of 
cicatrization depend uf)on the thickness of the cord, the inten- 
sity of the line of demarcation, and the reactive inflammation. 
The latter are most marked in vigorous infants. As a rule, 
the surface is dry a few days after the falling of the cord, and 
cicatrization complete within twelve or fifteen days after birth. 
This normal process is, however, disturbed by careless handling, 
local irritation, and infectious influences. In these cases there 
is a serous or purulent secretion, and cicatrization may be de- 
ferred for many weeks. Under these circumstances local treat- 
ment is required. Carbolic acid ought to be avoided, for the 
newly-born and infant are easily influenced by its poisonous 
properties. Solutions of lead, zinc, or alum answer quite well. 
As before, however, I recommend the powders of zinc oxide, 
bismuth subnitrate, alum with starch, salicylic acid with starch, 
or iodoform. Such measures will always prove helpful; to 
omit them in times of erysipelas or diphtheria is unpardonable. 
Perchloride of iron, or subsulphate of iron, must not be used. 
Under the hard coagulation formed by its application over the 
whole wound secretions will accumulate, cannot escape, are 
absorbed, and produce sepsis. I have seen babies die from 
applications of iron to the umbilical stump, as I know of 
women dying for the same reason when the hemorrhages from 
their uteri or from the lacerated vaginae were maltreated in the 
same manner. 

9. Omphalitis. 

Inflammatory infiltration of the abdominal integuments 
which surround the stump, with swelling, pain, purplish dis- 
coloration, gangrene, or abscesses, and consecutive peritonitis, 
occurs within a few weeks after birth, and is the result of trau- 
matic or septic influences. The dermatitis requires applica- 
tions of lead-wash ; tendency to suppuration, warm antiseptic 
(or aromatic) applications ; the presence of pus, a large incis- 
ion, with antiseptic after-treatment. Cold applications are not 



TREATMENT OF THE NEWLY-BORN. 59 

tolerated. Bathing is painful. Any of the antiseptics men- 
tioned will render good service. Carbolic acid must be avoided. 
Generous feeding by a wet-nurse, alcoholic stimulants (from 
one to two teaspoon fuls of whiskey daily), plenty of water, 
and evacuation of the bowels by injections, are the additional 
aids in treatment. The main reliance is on the local treat- 
ment, — viz., large incisions and antisepsis. 

10. Umbilical Gangrene. 

This is the result of an inflammatory process in a prema- 
turely-born baby, or one that fell sick with diarrhoea. It 
may extend inwards to the intestine and terminate in per- 
foration. The prognosis is very bad except in the few cases 
in which there is a well-marked line of demarcation. The 
treatment consists in antisepsis and stimulation. 

1 1 . Arteritis and Phlebitis. 

The former is very much more frequent than the latter. 
Arteritis is often connected with general sepsis, pneumonia, 
pleurisy, peritonitis, arthritis, and subcutaneous abscesses. 
The infection reaches the arteries from outside through the 
lymph circulation, begins in the connective tissue surrounding 
the vessels, and attacks the adventitia first. Budin succeeded 
in forcing septic material through the cord from beyond the 
umbilical ligature. Pus can seldom be squeezed out of the 
arteries, and the diagnosis is sometimes made at the autopsy 
only. The disease begins often before the complete separa- 
tion of the cord, absorption taking place through the cord, 
which dries and shrinks irregularly, and admits poison through 
the newly-formed cuts or fissures. 

The treatment is indicated by the causes, which are self-in- 
fection from a putrefying surface, infection by soiled fingers, 
cloths, baths, applications of any kind, the contact with a 
septic mother, or the contact with anything septic, — for in- 



60 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

stance, the pus of ophthalmo-blennorrhoea, or the decomposing 
lochial discharges of a healthy woman. Thus the treatment 
is mostly preventive. The scissors, cloths, and sponges used 
for the newly-born must be aseptic. The baby must not be 
in the mother's bed, and must be attended before the mother 
on the days following her confinement. The hands touching 
the baby's body must be carefully cleaned and disinfected, 
the cord and umbilical wound treated as detailed before. The 
internal treatment is identical with that advised in omphalitis 
and gangrene. 

The symptoms of phlebitis differ sometimes from those of 
arteritis in this, — that there is more peritonitis of the hepatic 
region from the beginning, more epigastric meteorismus, more 
icterus. Now and then pus can be obtained by gently squeez- 
ing along the course of the vein. The infection is either 
direct, through the vein, in which an ulcerous process is some- 
times found half an inch or an inch above the navel, or also 
through the lymph-current in the surrounding connective tissue 
and the adventitia of the vessel. The treatment cannot differ 
from that of arteritis. Recovery is possible when the absorp- 
tion of the poison has not been very copious, or elimination 
progresses with absorption at an equal rate. A female baby 
of less than three pounds, in my experience, exhibited no 
other source of septic infection but a slight erosion or ulcera- 
tion of the umbilical stump, with hardly any secretion. She 
recovered, though the process extended to the end of the second 
week, with temperatures reaching sometimes 103° F. 

12. Umbilical Hemorrhage. 

This may take place from the arteries, either before or after 
the separation of the cord. Its treatment is either mostly 
preventive, or the indications become so clear in every indi- 
vidual case that it becomes easy to fulfil them. Though the 
pulmonary aspiration and the great contractility of the mus- 



TREATMENT OF THE NEWLY-BORN. 61 

cular layers of the arteries render a hemorrhage difficult, 
though no ligatures have been applied, an insufficient develop- 
ment of those muscular fibres, or the presence of asphyxia or 
atelectasis, or a pneumonia, may produce a disposition to bleed. 
In such cases it may become necessary to apply an additional 
ligature. The arterial power being greatest in the abdominal 
cavity and near the umbilical ring, the cord must not be cut 
near the body. Two ligatures, as described above, are a fair 
preventive. Tight bandages impede circulation, and must be 
avoided. When the cord is cut too short, or torn off, it may 
be impossible to secure the vessels ; in such cases two long 
harelip needles must be run through the abdominal wall, 
crosswise, and a strong ligature tied underneath them. The 
same procedure may be resorted to when the hemorrhage takes 
place after the separation of the cord, either from the blood- 
vessels, or from the slowly-healing surface, in consequence 
mostly of inconsiderate handling. A moderate compression 
of the wound, which has been covered with iodoform or the 
salicylic acid and starch-powder, and borated cotton, by means 
of a bandage, will answer well. 

All of such cases yield a better prognosis than those resulting 
from haemophilia, congenital syphilis, general sepsis, or acute 
fatty degeneration. In these conditions the blood coagulates 
with even greater difficulty than that of the healthy new-born, 
and not infrequently all attempts at stopping the bleeding are 
liable to prove futile. The ligation of the whole mass is often 
unsuccessful because the stitch-channels will also bleed ; chemi- 
cal styptics are too often useless; plaster of Paris has some- 
times proved successful, and the actual cautery has proved 
advantageous in a few cases. But the majority of such cases 
terminate fatally. 

13. Icterus. 

A certain degree of yellowish discoloration of the skin is 
the result of the normal changes of hsernatin deposited in the 



62 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

skin during the rapid transition from foetal to post-natal cir- 
culation. When by retarded separation of the newly-born 
from the mother, and compression of the placenta, the amount 
of blood in the circulation of the infant is unduly increased, 
this form of hsematogene jaundice is rather more developed. 
The simplest form of hepatogene icterus is produced by the 
sudden diminution of the blood circulating in the vessels of 
the liver, which encourages the exosmotic transition of bile 
into the adjoining blood-vessels. All of these forms of jaun- 
dice require no treatment. Duodenal catarrh will produce 
icterus in the newly-born, as it does in advanced age. Thus 
the feeding and the digestion of the baby must be carefully 
watched. The routine administration of syrup of rhubarb is 
a mistake on the part of the female busy bodies which must 
be discouraged. Maybe some of them can be taught that 
acid cow's milk and indiscriminate feeding in general, and ex- 
posure, tight bandaging, and cold feet, can do still more harm 
than their medicines. Icterus resulting; from congenital oblit- 
eration of the large biliary ducts, or congenital cirrhosis, or 
acute fatty degeneration, or epidemic hemoglobinuria is in- 
curable. Icterus during septic infection is a bad symptom, 
and rarely terminates otherwise than in death. Icterus de- 
pending on congenital syphilis of the liver is grave, but I 
have met with several cases which recovered. A thorough 
and energetic antisyphilitic treatment is in such cases the only 
safeguard. It may prove unsuccessful, however, because the 
syphilitic process of the connective tissue is not confined to 
the liver, but extends to the rest of the organs. Mercury 
must be administered for a long time, a twentieth or a twelfth 
of a grain of calomel three times a day; careful inunction of 
a scruple of blue ointment daily ; or one-thirtieth of a grain of 
corrosive sublimate in a one-fifth of a per cent, solution of dis- 
tilled water for subcutaneous injection daily. In the beginning 
of the treatment two of these medications may be combined, 



TREATMENT OF THE NEWLY-BORN. 63 

or one of these together with the internal administration of 
from three to five grains of iodide of potassium. The in* 
ternal administration of the bichloride of mercury is also well 
tolerated; one-hundredth of a grain may be given in a tea- 
spoonful of water, or food, every two or four hours, and con- 
tinued many weeks. 

14. Melcena. 

The quantity of blood evacuated from the bowels is some- 
times enormous, particularly in view of the fact that the 
weight of the blood in the body of the newly-born amounts 
to little more than five per cent, of the weight of the baby. 
The cases complicated with vomiting are the worst. These 
are the results of the presence of ulcerations in the stomach 
and duodenum. Competent respiration and an aseptic umbili- 
cal wound are the best preventives. The treatment consists 
in applications of ice to the epigastrium, while the limbs 
are kept thoroughly warm by artificial means. Tincture of 
chloride of iron may be given in drop doses. Food is to be 
given at a low temperature. 

15. Tinsmus and Tetanus. 

Its prognosis is not quite so bad as it was believed to be 
formerly. Now and then recoveries have been reported, and 
I have seen them myself, though the number of cases ob- 
served by me have not been very numerous. The prognosis 
is better when trismus appears at a later period after the sepa- 
ration of the cord than usual, and when its course is protracted. 
Cases lasting more than five or six days are rather promising. 
Such as set in early and exhibit a high temperature (106° and 
more, up to 111°), disturbances of respiration, and great in- 
anition are bad. As a preventive, it has been proposed to 
remove women, for the time of their confinement and re- 
covery, from districts where trismus is endemic. At all 



64 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

events, the greatest care must be taken of the umbilical 
wound, through which the infection takes place. Food must 
be introduced through the rectum or the nose. For days after 
no food can be introduced into the mouth ; the patients are 
sometimes able to swallow whatever is introduced into their 
pharynx. By means of a medicine-dropper or a small tea- 
spoon fluids may be poured down. Medicines must be ad- 
ministered subcutaneously, atropise sulphas in doses of one 
one-thousandth or one six-hundredth of a grain a number 
of times daily ; curare, one-fiftieth or one-thirtieth ; extract 
of calabar, one-half of a grain. A few of my cases got well 
with chloral, mostly per rectum, in doses of from one to five 
grains from six to ten times a day. High temperatures may 
be influenced by antipyrin or antifebrin. Bathing is contra- 
indicated because the baby bears no handling. 

16. JBlennorrhcea. 

Blennorrhoeic conjunctivitis may be prevented by repeated 
disinfectant injections into the vagina of the woman in labor. 
For that purpose a solution of three parts of carbolic acid 
in one hundred of water, or one of bichloride of mercury 
in one or two thousand of water, are sufficient. After the 
newly-born has been bathed, a few drops of a two-per-cent. 
solution of nitrate of silver, or a one-twentieth of a per-cent. 
solution of bichloride of mercury, are applied to the cornea. 
When the disease is established, both eyes are affected in 
most cases. When but one, the healthy eye must be covered 
with a disinfecting lotion and borated cotton, and its infection 
by sponges, towels, water, and fingers guarded against with the 
greatest care. The diseased eye must be kept scrupulously 
clean by pouring tepid water over the cornea, or (and) re- 
moving the pus by means of small pellets of borated cotton. 
To succeed in this the upper and lower eyelids must be turned 
out. This is not always easy, and is never satisfactory unless 



TREATMENT OF THE NEWLY-BORN. 65 

the cornea becomes perfectly visible during the manipulation. 
Once a day the application of a mitigated stick of nitrate of 
silver (nit. arg., 1 ; nit. sod., 2) is useful. It may be sub- 
stituted by a two-per-cent. solution of nitrate of silver in 
water. In both cases the surface must be washed with a 
mild solution of table-salt afterwards, and ice-cloths, small 
and as dry as possible, applied every ten minutes or oftener. 
When the cornea is ulcerated, a few drops of a solution of 
sulphate of atropia (1 to 200) may be instilled several times 
daily. 

1 7 . Umbilical Fungus. 

The umbilical stump requires frequent inspection. Unless 
it cicatrizes speedily, granulations will spring up from its 
surface and form into small tumors. They are either sessile 
or pediculated, and are apt to grow very fast. They are not 
sensitive, but apt to bleed. In some cases they are discovered 
on very close examination only, and may remain many years, 
even to advanced age. Exceptionally such a fungus is not, or 
but partly, the result of granulation, but consists mainly of 
the remnants of the omphalo-mesenteric duct (with unstriped 
muscular fibres, tubulated glands, and cylindrical cells) or 
allantois. Once it was found by Virchow to be a sarcoma. 

It requires no excision. When it is pedunculated a silk 
ligature may be applied, and, after it has come away, the 
stump treated. Otherwise the little tumor requires cauteriza- 
tion or astringent and antiseptic applications. Nitrate of sil- 
ver may be used, but must be neutralized by chloride of sodium 
immediately. Other applications are, a drop of liquor sub- 
sulphatis ferri once or twice daily ; the powdered subnitrate of 
bismuth ; iodoform ; one part of salicylic acid with five parts 
of starch. 

18. Hernia. 

Congenital umbilical hernia (exomphalus) is called a fissure 
of the median line of the abdominal wall, which is the result 

5 



66 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

of an arrest of development. When the fissure is but small 
and the sac contains intestine only, the condition is incurable. 
When the sac is large, containing at least a portion of the 
liver, together with intestine, the contents may be reduced and 
the cases cured. Twenty-four such cases have been collected 
by Kocher.* C. Brenz reports the case of a girl weighing 
two thousand seven hundred grammes at birth. When the 
hernial sac had been reduced, which was accomplished with 
difficulty, he compressed the sac by means of a pair of pincers, 
removed it with scissors, applied three percutaneous ligatures, 
removed the clamp, applied the actual cautery to the stump, 
and covered it with antiseptic dressings. Both these and the 
ligatures were removed on the eighth day. The case proved 
successful, though there was peritonitis as early as twenty-four 
hours after birth. 

Acquired umbilical hernia, which contains small intestine 
and' peritoneum, and is produced by a large size of the cord, 
leanness and insufficient development of the baby, and by 
screaming, coughing, and the straining consequent upon di- 
arrhoea, constipation, phimosis, or anal fissure, demands re- 
duction, which is almost always quite easy, and retention, 
which is by no means so easy, within the abdominal cavity. 
The usual shape of trusses is unavailing, or even injurious. 
Whatever appliance is used must be larger than the aperture, 
and not be too hard. Linen or lint compresses, plates of cork, 
covered with linen or lint, may be held in position by means 
of a bandage, to which they can be fastened by stitches or pins. 
Knitted bandages are more useful than those of linen, cotton, 
or flannel. Adhesive plasters are used frequently, but are 
generally too irritating on the sensitive surface of the infant. 

Incarceration and strangulation of an umbilical hernia are 
very rare, but there is on record a fair number of cases in 

* A. Jacobi, Intest. Dis. of Infancy and Childhood, p. 267. 



TREATMENT OF THE NEWLY-BORN. 67 

which herniotomy was performed successfully in infants of a 
slightly advanced age. 

Inguinal hernia is a curable disease. When the short and 
straight inguinal canal of the newly-born becomes more ob- 
lique and the adjacent fat increases, in the course of a few 
years the rupture will disappear, provided a proper truss has 
been retained for a long time. During that period the intes- 
tines must not be allowed to protrude at all. The truss must 
be worn day and night, with the exception of such times- when 
the infant is sleeping quietly. A good fit does not mean 
undue pressure. The testicle must be closely watched. It 
is found high up in the scrotum behind the hernia. Some- 
times it has not descended into the scrotum, and is then mostly 
discovered in the inguinal canal. By gently pressing it down- 
wards and applying the truss above, we not only protect it 
but facilitate a complete descensus. 

19. Congenital Constipation. 
Malformations of the intestinal tract, such as strictures or 
complete interruptions, will either terminate fatally or require 
surgical treatment. The latter class includes imperforate anus 
and rectum. In these cases, where the obstruction is complete, 
we cannot speak of constipation. This condition may, how- 
ever, be found to depend on an anatomical peculiarity which 
is quite frequent, and may give rise to mistakes in diagnosis 
and treatment. The colon descendens of the newly-born is 
quite long. The sigmoid flexure, which I have found to 
measure as many as thirty centimetres (twelve inches), is bent 
upon itself several times in the narrow pelvis. Thus the con- 
volutions of the intestine will press upon and compress each 
other* to such an extent as to result in obstinate constipation. 
In some extreme cases the babies died without or with colotomy, 

* A. Jacobi, The Intestinal Diseases of Infancy and Childhood, Detroit, 
1887, p. 184. 



68 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

which was performed on the strength of a mistaken diagnosis. 
The treatment of that congenital form of constipation must be 
adapted to the anatomical condition which gives rise to it. 
Rectal injections alone are rational. They must be made daily, 
at least once a day, and continued up to the completion of the 
fifth or sixth or even seventh year. At that period the normal 
relations of the several parts of the intestine are accom- 
plished, the pelvis becomes larger, and evacuation of the 
bowels easier. No purgative medicines must be resorted to, 
inasmuch as the obstacle is mechanical only. There is, how- 
ever, a single indication for their administration, — viz., those 
symptoms depending upon constipation, which point to the 
absorption of intestinal putrid gases above the obstruction. 
Septic fever, high temperatures, and serious reflex symptoms 
— such as convulsions — may require the speedy evacuation of 
the bowels. Though such occurrences be rare, they are some- 
times met with. 






GENERAL THERAPEUTICS. 69 

III. 

GENERAL THERAPEUTICS. 

Therapeutics of infants and children have enjoyed, or 
suffered from, their fate like "books" and those of adults. 
They have had their stages between the era of dull and igno- 
rant prescribing and that of impotent and conceited nihilism. 
But neither a deluge nor an absence of drugs make a physi- 
cian, nor do they contribute, when by themselves alone, to the 
welfare of a single individual or the community. 

Much has been said of the difficulty of a diagnosis in the 
diseases of infancy and childhood, and the consequent diffi- 
culty experienced in treating them. I do not believe that the 
diagnosis in the case of an adult is much easier. The latter 
will often mislead you intentionally, or because he is carried 
away by prejudices and preconceived notions ; the former may 
conceal by not being able to talk, but will certainly not tell an 
untruth. Besides, the ailments of children are but rarely 
complicated, and a single diagnosis tells the whole story. If 
it be not made, it is perhaps best for the practitioner not to 
attempt much doctoring, and for the patient to be left alone. 
For, happily, most diseases have a tendency to get well, either 
completely or partially, and many will run a more favorable 
course when not meddled with. 

This does not mean to say, however, that I discourage treat- 
ment even in such ailments as run a typical course extending over 
a number of days or weeks. On the contrary, I am opposed 
to the practice — much too common — of those who do not, for 
instance, wish to interfere with a whooping-cough because it 
finds its natural termination after several months. This is 
true, but many of the children find their natural termination 
also during these months. Every day of whooping-cough is 



70 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

a positive danger. A lobular pneumonia which occurs in the 
second or third month of the disease, and proves fatal or ter- 
minates in phthisis, would have been prevented if the original 
affection had been removed or relieved by treatment. A phy- 
sician advising no treatment in such cases as terminate un- 
favorably in this manner, ought to be made punishable in the 
state of the future. Nor do I approve of the practice of 
" meeting symptoms when they turn up." My responsibility 
is not lessened by my busying myself with subcutaneous in- 
jections of brandy when a collapse has set in which I ought 
to have foreseen and prevented, or with giving digitalis when 
on the fifth or sixth days of a pneumonia the pulse is flying 
up to 160 or 200. Anybody can perform that sort of per- 
functory expectative treatment extending from the first call to 
the writing of a death certificate. What I expect of a physi- 
cian is to know beforehand whether that individual heart will 
carry its owner through an inflammatory or infectious disease 
without requiring stimulation or not. Many a case might be 
saved by a few grains of digitalis, or another cardiac tonic, or a 
few efficient doses of camphor or musk, if administered in time. 

Altogether, it has always appeared to me most satisfactory 
to treat children. They are truthful, unsophisticated ; they are 
what they appear, and they appear what they are. In their 
pathology and therapeutics there is no mysticism, no faith- 
cure, no spiritism, nor any other diabolism. Their nature and 
that of their ailments are simple enough, but you must know 
how to understand them. Fortunately, children are no mere 
miniature editions of adults, and their ills and whims and their 
peculiarities must be known. 

There is one all-important principle in treating infants and 
children which cannot be repeated too often. They are very 
liable to become anaemic, to submit to general inanition, and 
suffer from failure of the heart in spite of its anatomical and 
physiological vigor. These facts render it urgent that the 



GENERAL THERAPEUTICS. 71 

physician never lose sight of the general condition of the 
patient while attending to a local disorder. 

The best treatment is preventive. Proper feeding and 
nursing of the infant prevent the numerous gastric and in- 
testinal diseases of the earliest period, which either destroy 
life at once, or lay the foundation of continued ill health. For 
that reason a rather large part of my literary labors has been 
dedicated to the questions of diet and hygiene. Attention to 
respiration and circulation and the functions of the skin are of 
similar moment. Bathing, cold washing, exercise, sufficient 
interruption of school hours, are subjects of vital importance. 
The best exercise of the child is play. Compulsory gymnas- 
tics in badly- ventilated localities cannot take its place success- 
fully. The summer vacations of school-children ought to be 
four weeks longer than they are. The public schools ought to 
be closed about the middle of June and reopened in the be- 
ginning of October. Some years ago the Harlem Medical 
Association and the Medical Society of the County of New 
York requested the Board of Education of the city to open 
the public schools on the third, in place of the first, Monday 
in September. The soundness of the principle was appre- 
ciated, and the necessity for such a change was acknowledged 
by the authorities, and therefore (!) the second Monday of Sep- 
tember was selected for the beginning of the school season, so 
as to afford the children an extra week's boiling in the city 
sun and an opportunity to lose, as they did formerly, the bene- 
fit derived from the summer vacation. The good effects of 
the excursions of the St. John's Guild, and the air funds, and 
the Sanitaria of the Guild, and the Children's Aid Society are 
steps in the right direction. 

Milk and drinking-water are safest when boiled. It is to 
be hoped that the practice of sterilizing milk devised by 
Soxhlet, of Munich, and planned by CaillS, of New York, 
and Rotch, of Boston, will prove successful. Mental and 



72 THEKAPEUTICS OF INFANCY AND CHILDHOOD. 

physical labor ought to be easy and pleasant. Factory work 
for children is an abomination, and not only a cruelty com- 
mitted against the individual child who is helpless, but a dan- 
ger to the future of the republic, which cannot be expected 
to thrive while the physical and intellectual development of 
the future citizen is crippled by the greed of the manufacturer 
and the recklessness or partiality of legislatures. 

In the administration of medicines excitement on the part 
of the patient must be avoided ; the nervous system of infants 
and children loses its equilibrium very easily. Fear, pain, 
screaming, and self-defence lead to disturbances of circulation 
and waste of strength. Preparations for local treatment or 
the administration of a drug must be made out of sight, and 
the latter ought not to have an unnecessarily offensive taste. 
The absence of proper attention to this requirement has been 
one of the principal commendations of " homoeopathy," what- 
ever that may have been the last twenty-five years. Still, the 
final termination of the case and the welfare of the patient are 
the main objects in view, and the choice between a badly-tasting 
medicine and a fine-looking funeral ought not to be difficult. 
In every case the digestive organs must be treated with proper 
respect; inanition is easily produced, and vomiting and diar- 
rhoea must be avoided. The most correct indications and most 
appropriate medicines fail when they disturb digestion; it is' 
useless to lose the patient while his disease is being cured. 

The administration of a medicament is not always easily 
accomplished. Indeed, it is a difficult task sometimes, but one 
in which the tact or clumsiness of the attendants have ample op- 
portunities to become manifest. For " when two do the same 
thing, it is by no means the same thing." Always teach a 
nurse that a child cannot swallow as long as the spoon is be- 
tween the teeth ; that it is advisable to depress the tongue a 
brief moment, and withdraw the spoon at once, and that now 
and then a momentary compression of the nose is a good adju- 



GENEEAL THERAPEUTICS. 73 

vant. That it is necessary to improve the taste as much as 
possible need not be repeated. Syrup will turn sour in warm 
weather, glycerin and saccharin keep ; the taste of quinine is 
corrected by coffee (infusion or syrup), chocolate, and " elixir 
simplex/' a teaspoonful of which, when mixed each time be- 
fore use, suffices to disguise one decigramme = one and a half 
grains of sulphate of quinia. Powders must be thoroughly 
moistened ; unless they be so, the powder adhering to the 
fauces is apt to produce vomiting. Capsules and wafers are 
out of the question, because of their sizes ; pills, when gelatin- 
coated or otherwise pleasant and small, are taken by many. 
The rectum and nose can be utilized for the purpose of ad- 
ministering medicines in cases of trismus, cicatricial contraction, 
or obstreperousness. Both of these accesses it may become 
necessary to resort to for weeks in succession. 

The effect of a medicine depends on its dose and the readi- 
ness with which it is absorbed and eliminated. The latter 
differs greatly. Curare is eliminated speedily, and must be 
repeated quite frequently ; iodide of potassium soon after its ad- 
ministration, but there are traces in the urine after some days; 
phosphate of lime appears in the urine and faeces directly; 
chlorate of potassium is excreted through the kidneys within 
a few hours, silver and mercury may take a long time, in 
exceptional cases. Absorption takes place the more readily 
the more the solution in which the medicinal substance is 
held is diluted ; but it depends greatly on the condition of 
the surface or tissue which is selected for the introduction 
of the drug. A horny skin absorbs but little ; inunctions 
require a clean surface, and are best made where the epi- 
dermis is thin and the net of lymph-ducts very extensive, on 
the inner aspect of the forearm and the thigh. A congested 
stomach, a catarrhal or ulcerated rectum, are more or less in- 
dolent, and disappoint our expectations quite frequently. That 
the doses must be adapted to the ages of the patients is self- 



74 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

understood ; but to establish fixed rules is more than merely 
difficult. To give as many twentieths of the dose of an adult 
as the child has years is a fair average; but this rule suffers 
from very numerous exceptions. Like foods which are toler- 
ated by the adult, but are not tolerated by the young, though 
their amounts be diminished in proportion to their years, so 
there are medicines which are not borne by the infant. Nor 
are the doses the same for every adult. As healthy persons 
thrive on different quantities of food, so there is a variableness 
in the amount of medicines required for a full effect. Besides, 
there are idiosyncrasies which in some forbid the use of a medi- 
cine apparently indicated and borne with success by others. 
There are those who respond quickly, and sometimes too 
quickly, to very small doses of opium; others in whom a 
minute trifle of mercury produces salivation. It is this class 
of cases which gives rise to much disappointment, and requires 
all the tact and foresight of a good physician. In some the 
system gets used to a drug after a short time. Babies, after 
having taken opiates for some time, demand larger, and some- 
times quite large, doses to yield a sufficient effect. Some 
drugs are required in proportionately large doses. Febrifuges 
and cardiac tonics, such as quinia, antipyrin, digitalis, stro- 
phantus, sparteine, convallaria, are tolerated and demanded by 
infants and children in larger doses than the ages of the pa- 
tients would appear to justify. Iodide of potassium may be 
given in doses of one or two drachms daily in meningeal affec- 
tions, while in the same, one of the heart tonics, caffeine, must be 
shunned because of its — under these circumstances — exciting 
and irritating effects. Mercurials affect the gums very much 
less in the young than in advanced age. Corrosive sublimate, 
in solutions of one to six or ten thousand, may be given to a 
baby of two years with membranous croup in doses of a fiftieth 
of a grain every hour or two hours, for five or six days in suc- 
cession, with rarely as much as the most trifling irritation of 



GENERAL THERAPEUTICS. 75 

the gums or the stomach and intestines. In urgent cases of 
hereditary syphilis it can be administered on a similar plan for 
weeks, and, somewhat modified, for months. 

The dose of a medicine depends no less on the mode and 
locality of its administration. Modern therapeutics favor as 
much as possible local medication, like modern pathology, 
which requires local diagnoses. Subcutaneous administration 
dictates smaller doses, the rectum mostly a slight increase. This 
is a subject, however, to which we shall return. The manner 
of application results also in different effects. The inunction 
of the officinal ointment of iodide of potassium is wellnigh in- 
ert; its effect is almost exclusively that of massage, for iodine 
makes its appearance in the urine after days only. Iodide of 
potassium in glycerin, rubbed into the skin a number of times, 
may eliminate iodine after a day, in lanolin after a very few 
hours. 

The rectum of the infant and child has been rising in the 
estimation of the practitioner since the times of thermometry ; 
for it is certainly the safest and easiest place where to take the 
temperature. For therapeutical measures it is also invaluable. 
Its importance for the purposes of alimentation has been 
detailed in a former chapter. 

The rectum of the young is straight, the sacrum but little 
concave, the sphincter ani feeble, and self-control gets de- 
veloped but gradually. Thus a rectal injection is easily either 
allowed to flow out or vehemently expelled. Therefore one 
which is expected to be retained must not irritate. The bland- 
est and mildest is a solution of six or seven parts of chloride 
of sodium in a thousand parts of water. This may be made 
to serve as a vehicle of medicine, unless incompatible with the 
latter, which will be but rare. An enema which is to be retained 
must be tepid and small in quantity, half an ounce or little 
more or less, and carried up well into the rectum, for the im- 
mediate contact with the sphincter may produce its expulsion. 



76 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

Care must be taken to exclude air from the syringe, which, for 
small quantities, must be a well-fitting piston syringe, of hard 
rubber, with a long nozzle. This must be well oiled, and in- 
troduced, not straight, but with a gentle turn, so as to avoid 
folds in the anal mucous membrane (in the same way a ther- 
mometer ought to be introduced). The nozzle must not be too 
thin, as it is liable to be caught ; the smallest nozzles of foun- 
tain syringes are therefore in most cases improper ; the larger 
size is more appropriate for any age. The injection must be 
made while the patient is lying on his side, not on his belly 
over the lap of the nurse, for in this position the space inside 
the narrow infantile pelvis is reduced to almost nothing. 

When medicines are to be injected, the rectum ought to be 
empty, as in infants it mostly is. When it is not, an evacu- 
ating injection ought to precede the medicinal one by half an 
hour. It ought to be of the mildest possible nature, for any 
irritation of the rectum, from the local effect of an enema 
to a catarrhal or dysenteric process, reduces its faculty of 
absorption. The medicinal solution must not be saturated ; 
indeed, very soluble medicaments only are to be selected for 
medicinal enemata. Nor must they be acid, or contain any- 
thing irritating. Alcoholic tinctures require relatively large 
quantities of water ; quinia salts must not be selected unless 
very soluble, such as the muriate, bromide, bisulphate. No 
acids must be used for the purpose of keeping them in solu- 
tion. Salicylate of sodium, also antipyrin, exhibit their full 
power through the rectum, and permit of full doses. As a 
rule, however, the rectal doses are a little larger than those 
given by the mouth. 

Larger enemata are not retained, and are therefore utilized 
for the purpose of emptying the bowels. This effect is easily 
obtained in infants and children, for their faeces are soft and 
movable, with the exception of those cases in which improper 
medicines (large and continued doses of lime and bismuth, or 



GENERAL THERAPEUTICS. 77 

astringents), or badly-selected food (casein and starch in undue 
quantities), or an excess of the normal great length of the 
colon descendens and sigmoid flexure have given rise to large 
accumulations of hardened faeces. Small quantities are seldom 
sufficient for the purpose of relieving the bowels, unless they act 
as irritants ; in this manner glycerin, pure or with equal parts of 
water, may produce an evacuation readily. An evacuant injec- 
tion may weigh from a fluidounce to a quart in some. It ought 
to be given while the child is lying down ; the liquid must not 
enter the bowels quickly or vehemently, the fountain syringe 
not being more than ten or twelve inches above the anus. If 
that precaution be observed, occasional pain, or faintness, or 
vomiting can be avoided. If water, or water with two-thirds 
of one per cent, of salts, be insufficient, more salt or soap may 
be added for the purpose of enforcing the evacuation. Haifa 
tablespoonful of oil of turpentine, with a pint of soap and 
water, acts often charmingly ; so does the addition of a few 
drachms of tincture of assafoetida, in conditions of constipa- 
tion, flatulency, and nervous excitability, also in convulsions, 
or glycerin in obstinate constipation. 

Large injections will have other indications besides that of 
evacuation of the bowels. In many cases of intense intestinal 
catarrh large and hot (104° to 108° F.) enemata will relieve the 
irritability of the bowels and contribute to recovery. They 
must be repeated several times daily. When such evacuations 
contain a great deal of sticky viscid mucus, the addition of one 
per cent, of carbonate of sodium will liquefy the tough secre- 
tion. When there are many stools, and these complicated with 
tenesmus, an injection, tepid or hot, must or may be made after 
every defecation, and will speedily relieve the tenesmus. In 
such cases flaxseed tea or a thin mucilage may be substituted 
for water. 

When the bowels are in a state of chronic catarrh or ulcer- 
ation, the injections ought to be particularly large and contain 



78 THERAPEUTICS OP INFANCY AND CHILDHOOD. 

astringent or alterant medicines. Though they be expelled 
immediately, enough of the dissolved or suspended remedy 
will remain upon the mucous membrane. Sulphate of zinc, 
alum, subacetate of lead, tannic acid, nitrate of silver, sali- 
cylic acid, carbolic acid, and creasote have been used in such 
medicated injections. One per cent, solutions will suffice. 
Salicylic and carbolic acid may prove uncomfortable or dan- 
gerous, and ought to be dispensed with. Nitrate of silver 
requires some precaution. From a grain to five grains or more 
in an ounce of distilled water may be safely injected, but this 
enema must be preceded by an evacuant one consisting of water 
only, and followed by one containing some chloride of sodium 
for the purpose of neutralizing the nitrate and protecting the 
anus and external parts from local irritation. It will also be 
found advantageous to wash the anus and perineum with salt 
water before injecting the silver solution. In many cases where 
one of the above-mentioned agents appeared to be tolerated 
badly, or proved inefficient, subnitrate (or subcarbonate) of 
bismuth mixed with water, or gum-acacia water, in different 
proportions, proved very acceptable and healthful. 

Suppositories are useful both for evacuating and medicinal 
purposes. Soap is utilized for the former purpose by the 
public at large, and the same material differently mixed, 
with or without medicinal additions, such as atropia, by the 
irregular trade. Local medicinal applications to the rectum 
are best made by means of injections, but a general effect is 
also obtained through a suppository. Opiates, and narcotics 
generally, exhibit their full power when the suppository is re- 
tained. Extract of hyoscyamus, from half a grain to a grain 
in a suppository, to be repeated from two to five times daily, 
shows its effect in vesical spasm nearly as well as when taken 
internally. Quinia is gradually dissolved and absorbed. Ex- 
tract of nux, both in ointments and in suppositories, acts well 
in prolapsus of the rectum and debility of the sphincter. 



GENERAL THERAPEUTICS. 79 

Subcutaneous injections of remedial agents ought to be made 
more frequently than appears to be customary. The extremi- 
ties ought to be avoided, for their constant motion and the 
relative absence of fat in their subcutaneous tissue are liable to 
give rise to local irritation, swelling, or suppuration. The 
abdominal wall is preferable. A sharp and aseptic needle 
and gentle friction of the injected part are all that is required. 
The solutions used must be clear and without any solid in- 
gredients. When they have been preserved for some time 
they ought to be filtered before being used, particularly when 
fungous growths have begun to make their appearance in the 
liquid. The latter may be preserved best by adding a small 
quantity of alcohol, salicylic acid, or hydrocyanic acid. The 
doses must be small, and the medicine diluted more than in 
the case of adults. This is mainly required where a caustic 
effect is to be feared. While, for instance, Lewin advised for 
adults a solution of four grains of bichloride of hydrargyrum 
in an ounce of water, one or one and a half grains give a more 
appropriate solution for infants. One or two daily doses of 
eight or ten drops continued for weeks will prove very useful 
in those urgent cases of hereditary syphilis which are charac- 
terized by pemphigus on the soles of the feet and the palms 
of the hands in the first days after birth. Brandy and ether 
may be used undiluted as in adults, but the greatest care 
must be taken as to the locality injected. The subcutaneous 
tissue must be reached and the cutis penetrated. Chloral 
hydrate dissolves readily in two parts of water, but a solu- 
tion of one in four or six is better tolerated. For the ready 
symptomatic treatment of convulsions it renders good service. 
Antipyrin is well borne in solutions of one in six or eight 
parts of water, camphor in from four to six parts of almond 
oil. Digitalin, in solution, and the fluid extracts of digitalis 
and ergot, are very apt to give rise to indurations and abscesses. 
As a rule, the most convenient medicaments for hypodermic 



80 THEEAPEUTICS OF INFANCY AND CHILDHOOD. 

administration are the very soluble alkaloids. One or three 
drops of Magendie's solution of morphia or the correspond- 
ing solution of muriate of morphia are vastly preferable 
to the internal use of narcotics for bad pain in pleuritis or 
pleuropneumonia, or in peritonitis. It may be mixed with 
atropise sulphas for the reasons regulating its use in the adult. 
The latter by itself has been found quite effective in the case 
of an epileptic boy, who had taken the same drug internally 
without any success. If possible, it ought to be injected 
during the aura; if not, twice a day. Apomorphise murias 
is a ready emetic in doses of a thirtieth or a fifteenth of a 
grain. Pilocarpise murias can be injected in doses of one- 
twentieth to one-eighth of a grain. Its reckless use, both 
hypodermically and internally, has led to occasional mishaps, 
but the drug is a powerful agent for good when carefully 
applied, and has saved for me several cases of meningeal 
hyperseniia and cerebral oedema, mostly of nephritic origin. 
Sulphate of strychnia, while in the same affections it has 
mostly proved inefficient when taken internally, has rendered 
efficient services in enuresis depending on paralysis or weak- 
ness of the sphincter of the bladder, and in prolapsus of the 
rectum, and faecal incontinence resulting from paralysis of the 
anus, which depended either on disease or congenital incompe- 
tency. In these cases a daily dose of a fortieth or a twenty- 
fifth of a grain — according to the age of the patient or the 
severity of the case — is sufficient. More frequent doses, how- 
ever, are required in the diphtheritic paralysis of the respira- 
tory muscles, which is dangerous and apt to become fatal unless 
speedily relieved. A daily dose will also yield fair results, 
when long continued, in spinal or cerebral paralysis. Quinia 
salts must be neutral when injected ; I prefer the bromide, the 
muriate, or the carbamide. They, particularly the last, are 
among the most soluble. The carbamide dissolves readily in 
from four to six parts of warm water ; the latter temperature 



GENERAL THERAPEUTICS. 81 

ought to be preferred in every case of suocutaneous injections. 
Quite saturated solutions ought to be avoided, because it has 
happened to me that the water of the solution was speedily 
absorbed, and the quinia remained as a foreign body in the 
subcutaneous tissue. Caffeine, in its combination with sodium 
and salicylic or benzoic acid, is an excellent heart stimulant, 
and has rendered splendid service in urgent cases of heart- 
failure or pulmonary oedema depending on cardiac disease. 
Both the salicylate and the benzoate of sodium and caffeine 
are soluble in two parts of water, and are readily absorbed. 
Neither has, as yet, been prepared in the convenient tablet 
form which has proved so acceptable in the cases of other 
alkaloids. Both must be avoided in those cases which are 
complicated with cerebral irritation. Fowler's solution, care- 
fully filtered, may be injected into healthy or morbid tissues 
without often risking irritation and abscess. Still, I have seen 
a splenic abscess after such an injection in a case of sarcoma 
of the spleen. Undoubtedly, the continued use of arsenic ren- 
ders very efficient services in sarcoma ; but as it has to be used 
a very long time, it is almost useless, except in hospital prac- 
tice, to rely on hypodermic medication. There is no harm in 
this, however ; for a very gradual increase of the drug is toler- 
ated to such an extent that, after awhile, very large doses 
(amounting to half a drachm or a drachm daily) of Fowler's 
solution may finally be administered. 

Inhalation is resorted to in two different ways. Either the 
air of the room or a tent is impregnated with the substances 
to be introduced into the air-passages, or these substances are 
introduced through sprays or atomizers of different shapes and 
patterns. Some of the latter have always appeared to me 
very faulty, and not to the purpose at all. Tubes introduced 
into the mouth, through which substances are to be carried 
down, will land them in the mouth ; it takes all the self- 
control and intelligence of an adult patient to allow the object 



82 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

in view to be accomplished. The oral cavity is small, the 
tongue gets coiled up, and the faucial muscles will not relax. 
Nose and mouth must co-operate to allow inhalations to enter 
the larynx, or the former alone must be relied on. A spray 
calculated to reach the larynx is always best introduced into 
and through the nose. In this way, at all events, the poste- 
rior part of the pharynx and the respiratory tract are reached 
to best advantage. 

Real inhalation, however, means filling the lungs with a gas 
or vapor. Warm steam will do good service in bronchitis 
and pneumonia, when the bronchial secretion is viscid and 
expectoration difficult, and in diphtheria, for the purpose of 
softening membranes and increasing the secretion of a thin 
and normal mucus. Cases of fibrinous bronchitis I have seen 
getting well in bath-rooms, the hot water being turned on for 
days in succession and the air thick with steam. An excel- 
lent inhalation in the inflammatory conditions of the respira- 
tory organs is that of muriate of ammonium. Every hour, 
or in longer intervals, a scruple or more of the salt — the 
quantity depending in part on the size of the room — is burned 
on the stove, or over a live coal or an alcohol lamp. The 
heavy white cloud fills the room, is easily borne by both sick 
and well, and improves expectoration. Oil of turpentine can 
be utilized in a similar way. Its action is both expectorant 
and disinfectant. In the latter stages of pneumonia, when 
the bronchial secretion is thick, viscid, or deficient, and ex- 
pectoration and cough are wanting, the room may be filled 
with turpentine vapor. This can be accomplished in dif- 
ferent ways. A large soft sponge may be soaked with tur- 
pentine, with or without the addition of some oil of sassafras, 
and suspended at the bedside. Or a kettle may be kept boil- 
ing day and night with water, on the fireplace or over an 
alcohol lamp (which is preferable to a gas-stove, which consumes 
too much oxygen), and a tablespoonful of turpentine, more or 



GENERAL THERAPEUTICS. 83 

less, poured on the boiling water every hour or two hours. 
The same may be done to advantage in diphtheria, with or 
without a teaspoonful of carbolic acid in addition to the tur- 
pentine, and in gangrene of the lungs. The inhalation of 
benzin, cresolin, and similar substances, and the coal-gas of 
the gas-factories, have been amply recommended in whooping- 
cough. In its worst forms, particularly when it is compli- 
cated with convulsions, the frequent inhalation of chloroform 
is sometimes life-saving. A baby of six months, with hourly 
attacks of convulsions, I kept alive by putting him under 
the influence of chloroform at the beginning of every attack, 
and continuing that treatment for fully four days. Asthmatic 
attacks will do well sometimes with inhalations of chloroform, 
ether, and spirits of turpentine in different proportions. Ni- 
trite of amyl also will influence them favorably ; as a preven- 
tive of epileptic attacks I have experienced but little success 
with its administration. But in collapse, with paralysis of 
peripherous blood-vessels, it certainly renders good service. 
With the inhalation of oxygen for the purpose of bridging 
over the most dangerous period of a suffocating pneumonia, 
and of improving tissue-change in general anaemia and ill- 
nutrition, the profession is well acquainted. With the inhala- 
tion of ether as an antidote to poisoning with santonine I have 
no personal experience. 

In pulmonary tuberculosis the inhalation of disinfectant 
vapors is employed less than the necessity of the cases appears 
to indicate. Carbolic acid, turpentine, eucalyptol, may be 
utilized for that purpose. The object is to supply the lungs 
with those substances in thin dilutions, but constantly. Prud- 
den has proved that carbolic acid in twelve hundred parts of 
water stops the emigration of leucocytes in inflammatory 
disorders. Thus high dilutions, though they be hardly per- 
ceptible to the senses, and certainly not to a disagreeable 
extent, are amply sufficient. It is for this reason that Feld- 



84 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

bausch invented small apparatuses filled with a disinfectant 
substance to be worn in a nostril, constantly. 

The inhalation of chloroform, which is preferable to ether 
for the purpose of producing anaesthesia in the cases of in- 
fants and children, is rather unsatisfactory at the earliest age 
because of the superficial character of respiration. Its effect 
is very temporary, and the administration must be repeated 
during a convulsion or an operation. The difficulty in ob- 
taining a complete narcosis is particularly great in the newly- 
born. The stage of excitement is but brief, the pulse becomes 
frequent, and the pupils contract. After a short time the pulse, 
however, becomes slow, and the pupils dilate. The after-effects 
are not so inconvenient as they often prove in the adult ; chil- 
dren vomit less frequently and less profusely, and certainly with 
greater facility and ease, than adults. They are liable to re- 
main under the influence of the anaesthetic a long time after 
an operation has been completed. After tracheotomies, which 
I never performed without chloroform unless the children 
were asphyxiated by carbonic acid poisoning, the patients are 
apt to sleep long and undisturbed. Thus they require a 
ceaseless watching until the effect has surely passed away. 
Through the opened trachea the children will get under the 
influence of chloroform very easily. Five or six drops on a 
sponge or some absorbent cotton, held in the mouth of the 
tube by means of a pair of pincers, have an almost instan- 
taneous effect, and came near destroying a successful case of 
mine nearly thirty years ago, before I had the experience 
detailed in the previous remark, when I undertook to change 
the tracheal tube on the third day. Further care is also re- 
quired in regard to patients in ill health. Chronic pulmonary 
and heart diseases do not tolerate chloroform very well, but 
the diagnosis of these conditions is more readily and quickly 
made in children than in the adult. Adipose children are 
liable to faint. Operations in the mouth it is best to perform 



GEKEKAL THEKAPEUTICS. 85 

without an anaesthetic, for the amount required to overcome 
the resistance of the masseter and buccinator is so large, gen- 
erally, as to possibly endanger the life of the patients, beside 
the impossibility of obviating successfully the entrance of 
blood into the digestive organs, where it is inconvenient, or 
the respiratory organs, where it is a positive danger. 

Gargles of any description require a certain degree of train- 
ing and self-control, and are therefore not available for children 
of less than seven or eight years. The liquids thus employed 
do not reach any farther than to the uvula, the pillars of the 
soft palate, and the anterior part of the tonsils. Whatever 
succeeds in passing them is swallowed. Thus the alleged effi- 
cacy of gargles is greatly overestimated. Astringents only 
have a certain influence reaching beyond the area of contact 
through their secondary effect on contiguous tissue. When a 
thorough effect is aimed at, it is better to rely on sprays, which 
may affect the whole pharyngeal cavity, or on insufflations of 
powders. As, however, in most cases where a local effect on 
the pharynx is desirable, the local affection spreads over the 
posterior nares as well, spraying, or injecting, or irrigating 
the nose is preferable. The liquids thus employed reach the 
pharynx, and are either swallowed — which is often an indif- 
ferent matter — or expelled through the mouth. When these 
methods are undesirable, for instance, when the liquids in- 
jected enter the Eustachian tube, they may be poured into 
the nasal cavities from a teaspoon or a pipette. A common 
medicine-dropper will often suffice. There is many a case of 
diphtheria in which the very gentlest method of cleansing and 
disinfecting the surface of the naso-pharyngeal cavity ought to 
be selected. 

When no liquids are tolerated, fluid ointments may be 
introduced into the nostrils by means of a camel-hair brush, 
or poured in. Ointments prepared with vaseline, glycerin, or 
cold cream are good vehicles for that purpose. Sponges and 



86 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

brushes ought to be avoided whenever the young patient 
objects to these strenuously. No violence must be used, for 
several reasons. The child's strength must not be exhausted 
by his attempts at self-defence, and most local affections of the 
throat get worse by any injury done to the epithelia. Even 
galvano-cauterization can and must be applied without much 
violence. Persuasion, patience, and cocaine will render it 
possible. 

The skin in infancy and childhood participates in the an- 
atomical structure of all the tissues at that early period, 
inasmuch as it contains more water than in advanced age. 
Besides, it is thinner. This explains many peculiarities in 
regard to the effects of many medicaments. Electricity in all 
its forms is more efficient, and a relatively mild current suffices. 
This fact is of particular importance, as, moreover, the bones 
also are thinner and more succulent. To act upon the brain, 
very mild currents only must be used. The spinal cord is 
less accessible, and appears to require rather large doses. 
The galvano-caustic effect resembles very much that obtained 
in the adult. In most cases it can be watched while being 
employed ; thus, for instance, in the operation on angiomata, 
or diseases of the tonsils or nose. 

Sinapisms, when not mixed with flour, must not be per- 
mitted to remain more than a few minutes. As soon as the 
skin begins to be discolored they must be removed. When 
that is done, they may be repeated every few hours, and they 
are active derivants in many cases of deep-seated congestive 
processes. The same remark is due in reference to the use of 
mustard-baths. A hot mustard-bath renders good services in 
suppressed or insufficient cutaneous eruptions of an acute char- 
acter, internal hemorrhages, meningitis, and pneumonia. But 
it must not be continued beyond reddening the skin. 

Vesicatories have lost much of the esteem in which they 
were held in former times. I remember the time when many 



GENERAL THERAPEUTICS. 87 

a case of pleurisy, articular inflammation, herpes zoster, was 
not permitted to get well without a Spanish-fly blister. Nor 
am I of the opinion to-day that it will do no good in some 
such cases, provided it be not used during the feverish stages. 
But their drawbacks are many. A plaster will not stick to 
an emaciated and uneven surface, and is even apt to give rise 
to gangrene when the surface circulation is very defective. In 
these cases the wound will heal badly. The skin of the in- 
fant being very vulnerable, eczema, and impetigo will easily 
arise on even slight provocation. The local pain of the ap- 
plication produces irritation, nervousness, and sleeplessness. 
This is particularly so if the application be made on the ex- 
tremities or the posterior surface of the body. The kidneys 
are frequently affected by cantharides, dysuria being the result 
in many cases, which then require energetic camphor treatment 
for the relief of the torturing symptoms. 

There are some absolute contraindications to the external 
use of cantharides : the presence of diphtheria in any shape 
or manner, and such diseases as are liable, during the preva- 
lence of an epidemic, to become complicated with diphtheria. 
Therefore no vesicatory must be used during nasal, pharyn- 
geal, or laryngeal diphtheria (croup), or in the different forms 
of pharyngitis, or in laryngeal catarrh. 

When a plaster cannot be expected to remain on the surface 
and to have its full effect, cantharidal collodion may take its 
place. The application will prove more effective when the 
surface is first washed with vinegar, or irritated by a sina- 
pism, which, however, is allowed to remain a few minutes 
only. Then a flaxseed-poultice or warm-water applications 
may be applied over the vesicatory to diminish the pain and 
increase the effect. Very young infants ought not to carry a 
vesicatory more than an hour, at least not on the same spot. 
It is for this reason that to them the cantharidal collodion is 
less adapted. The plaster may be shifted from place to place. 



88 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

After the epidermis has been raised, the serum must be 
allowed to escape through small punctures, but not so as to 
moisten the adjoining parts, for the cantharidin contained in 
the serum may exert a disagreeable local effect. The epider- 
mis ought not to be removed, and no irritating ointment used 
to keep up a secretion. To cover the sore surface, vaseline or 
cold cream are preferable to animal fats, which may be, or 
become, rancid. The best final dressing is borated cotton and 
a bandage. Vaseline ointments with opium, lead, or zinc, and 
powders of zinc, subnitrate of bismuth, iodoform and amylum, 
in equal parts, or salicylic acid one part, with five or ten of 
starch, will find their occasional indications. 

In many affections of the skin powders, solutions, liniments, 
ointments, and baths are employed. The skin is thin and 
irritable. Erythema will follow the contact with water quite 
often ; thus many forms of dermatitis contraindicate its fre- 
quent use. Acute and chronic eczema get on better without 
than with it. Therefore astringent solutions are less advisable 
than astringent ointments. For superficial effect these must 
be prepared with vaseline or cold cream, either of which may 
be readily combined with lead, tannin, zinc, bismuth, salicylic 
acid, or iodoform. In not a few cases, with a very sore sur- 
face, denuded of its epithelium and oozing, the powders alone, 
or combined with starch in different proportions, will prove 
very effective Oleates ought to be avoided, — they irritate 
the skin and produce eruptions. 

As the skin is thin and succulent, and the lymph-ducts quite 
superficial, large, and numerous in the young, substances will 
penetrate the skin quite readily. Ointments with that object 
in view must be prepared with animal fats, particularly with 
lanolin, to which ten per cent, of water must be added. Still, 
much friction may by itself irritate the surface and give rise 
to suffering. 

In the very young, ice and ice-water applications are not 



GENERAL THERAPEUTICS. 89 

tolerated a long time. Ice to the cranium, the bones of which 
are but thin, is liable to produce collapse; about the neck and 
occiput it is better borne and often beneficial. Warm fomen* 
tations and hot poultices are very beneficial in many morbid 
conditions of the trunk and extremities, but dangerous when 
applied to the head and not carefully watched. General baths 
are frequently required, local baths but seldom ; foot-baths may 
be given while the patient is lying down, but hot fomentations 
are more readily made, and do not require the same amount 
of watching, nor are they equally objectionable to the young 
patient. 

Depletions were frequently resorted to scores of years ago. 
Modern practice has learned how to do without them, though 
we may be willing to assume that they were more frequently 
indicated than many of us believe at present. At all events, 
it ought to be taken into consideration that there is but a single 
pound of blood in a baby of twenty pounds, and that a patient 
rapidly reduced by sickness is least able to stand a loss of blood 
ever so small. Thus a venesection will hardly ever be thought 
of; at all events, I hope never to repeat the opening of a jug- 
ular vein, practised by me in a case of convulsion depending 
on, and increasing, cerebral congestion, a quarter of a century 
ago. Local depletions were once more frequent, though the 
liability of the skin to inflammation and furuncle was well 
understood, and the excitement of the little patient was such, 
now and then, as to lead to an increase of the symptoms, and 
even to convulsions. Among the occasional drawbacks was 
also the possible loss of blood after the leeches had fallen off. 
In such a case the local use of tannic acid, alum, perchloride 
or subsulphate of iron, digital pressure, or in bad cases the 
ligature underneath a harelip needle, which was inserted 
through the wound, were resorted to. The indications were 
bad and painful cases of pleurisy and peritonitis, and cerebral 
inflammatory diseases. In the latter, the mastoid process and 



90 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

the septum nariuni are the points on which the leech or leeches 
ought to be applied. It is the latter spot which I prefer, when 
I have the choice, in such rare cases of brain-diseases of in- 
fants and children in which I still feel justified to recommend 
a depletion. 



CONSTITUTIONAL DISOEDEES. 91 

IV. 

CONSTITUTIONAL DISOEDEES. 

1. Anaemia, 

Anemia is often the result of a hereditary predisposition, or 
congenital from some accidental cause. Mothers who suffered 
much during their pregnancies, or were delicate themselves, 
are liable to give birth to anaemic and puny infants. Prema- 
ture infants, or those afflicted with congenital diseases, such as 
" cyanosis" or neoplasms, or smallness of heart and arteries, 
are anaemic, and apt to remain so. Another cause of idio- 
pathic or primary anaemia is found in actual loss of material 
by copious suppuration, excessive exudations in pneumonia 
and pleurisy, or real hemorrhages, the results of which are 
sometimes not relieved through a whole lifetime. They are 
quite frequent in the newly-born or young, in true melaena, 
haemophilia, umbilical bleeding, cephalhematoma ; from hare- 
lip operations or ritual circumcision ; from rectal polypi ; from 
coryza, heart-disease, or abdominal stagnation, as epistaxis ; or 
from ulcerations in diphtheria. 

As these papers are meant to discuss therapeutics only, I 
cannot do more than simply allude to the direct and indirect 
causes of anaemia for the purpose of obtaining the indications 
for treatment. Among the former are prominent the admin- 
istration of an insufficient amount or an improper composition 
of food and insufficient supply of oxygen. Among the latter 
I count every disease of more than a very temporary charac- 
ter ; all those ailments which so change the alimentary digestive 
organs as to interfere with digestion ; diseases of the organs of 
respiration, circulation, and elimination (kidneys) ; all fever- 
ish diseases, and particularly the infectious fevers (scarlatina, 
malaria, least of all typhoid fevers, unless they result in chronic 



92 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

intestinal ulcerations) ; diseases of the lymph system, the larger 
part of which are accessible to successful treatment. It is true 
that pseudo-leukaemia offers the same difficulties which we 
meet in the adult; but the many glandular swellings — " scrof- 
ulous" or not — permit of successful treatment, both preventive 
and curative. 

All these affections, the number and names of which I do 
not care to multiply, are the more dangerous, and require the 
more dietetic and medicinal attention, the greater their detri- 
mental influence during infancy and childhood, — that is, during 
the period of growth, in which the organism has not only to 
sustain itself, but to increase steadily. The latter consideration 
is a very important one. It includes the necessity to which I 
have alluded in a previous chapter, not to permit a morbid 
condition, either acute or chronic, to exhaust itself without in- 
terference. A disease shortened a day, a sleepless night less, a 
dozen of diarrhceal movements prevented, a racking cough 
soothed, a convulsion interrupted, an excessive temperature re- 
lieved, are just as many prophylactic points gained, and as 
many causes of persistent anaemia mitigated in their dangerous 
influences. 

These considerations are the more weighty the younger the 
patient. For in regard to anaemia the young are in a very 
precarious condition indeed. The infant (and child) has less 
blood in proportion to its entire weight than the adult ; this 
blood has less fibrin, less salts, less haemoglobulin (except in the 
newly-born), less soluble albumen, less specific gravity, and 
more white blood-corpuscles. It has a specific gravity of but 
1045 or 1049 compared with that of 1055 in the adult. The 
total amount of the blood in the young is relatively small. 
Its weight, compared with that of the body in the newly-born, 
is 1 : 19.5. The relative figures in the adult are 1 : 13. 

Hence it follows, from a practical point of view, that it is 
important not to permit the relatively small amount of blood 



CONSTITUTIONAL DISORDERS. 93 

in an infant or child to be unduly diminished or diluted. 
Thus the subject of feeding and digestion is of such paramount 
weight in pediatrics. 

While it is a good rule to be careful in regard to the amount 
of food to be allowed in the beginning of a feverish disease, a 
fair quantity must be allowed after a while, provided it is 
fluid and well selected. Unless there be a contraindication in 
the condition of the stomach, mostly albuminous nutriment 
must be administered. During protracted diseases the danger 
of inanition becomes imminent, still more in the young than 
in the adult. Convalescence requires generous feeding and 
stimulation also, with this restriction, that the meals must 
be small and frequent, and the stomach sustained all the 
time. In this way many a case of secondary anaemia may be 
avoided. 

Babies become anaemic when their mothers or nurses have 
too little milk, or when the supply is ample but of an improper 
quality. Nursing during a subsequent pregnancy must be for- 
bidden. It must not be continued too long, certainly not be- 
yond the protrusion of the first group or groups of incisors. 
Nor must it be continued beyond the tenth month if at that 
time no tooth has made its appearance. Many a case of 
anaemia or rhachitis will be cured by a change of such faulty 
diet. It is better for the baby to develop teeth, bone, and 
muscle on barley or oatmeal and cow's milk than to become 
rotund with oedematous fat, and anaemic on his mother's power- 
ful sympathy and powerless breast-milk. Maternal love does 
not improve the breast-milk of a person with a history of 
consumption, rickets, syphilis, nervous disorders, or intense 
anaemia. Sometimes even a healthy woman has a milk which 
is not adapted to that particular baby ; then another woman or 
artificial food must be preferred. The addition of barley or 
oatmeal and beef-soup or beef-tea is always advisable when a 
nursling becomes anaemic without having been afflicted with a 



94 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

tangible disease. A small piece of beef, half an egg daily, a 
crust of bread, may be added about the end of the first year. 
The diet ought to remain simple, and mostly fluid or semi- 
solid until the child is two years old. Avoid bad habits, such 
as fast eating, and enforce regular defecation, plenty of exer- 
cise out of doors, and undisturbed and long sleep in a cool 
room. Avoid crowded school-rooms and protracted lessons. 
" We have laws to protect children from being sent to work 
in factories, or to be employed on the stage, but none to 
protect them from the equally destructive, incessant schooling 
in close rooms, without air or exercise. There are too many 
books bought for Christmas, and too few skates."* 

The subject of nursing and artificial feeding, and of digestive 
organs, has been treated of but lately ;f thus I abstain from dis- 
cussing the matter here beyond the above fragmentary remarks. 
What, however, cannot be emphasized too much or too often is 
the necessity of resorting to animal food — soups, teas, peptones 
— in cases of infantile anaemia. 

The medicinal treatment of anaemia must fulfil the causal 
indications first. That which depends upon chronic gastric 
catarrh requires, according to circumstances, alkalies or hydro- 
chloric acid, pepsin, bismuth. Beside the well-known subcar- 
bonate and subnitrate, the salicylate has made many friends of 
late, deservedly. Pepsin and dilute hydrochloric acid are best 
combined ; a baby of a year may take six or eight drops of the 
latter in six or eight ounces of water daily, or the acid may be 
mixed with milk according to the formula given in a previous 
essay. Disease of the kidneys has its own indications. The 
regulation of the heart's action — which, when abnormal, is the 
most frequent cause of habitual epistaxis, and of gastric catarrh 



* Archives of Medicine, vol. i. p. 1, February, 1881. 
f A. Jacobi, " The Intestinal Diseases of Infancy and Childhood." — 
Detroit, 1887. 



CONSTITUTIONAL DISORDERS. 95 

and hepatic congestion — is the first indication in secondary 
anaemia. Many a gastric catarrh will not get well without 
digitalis or some other cardiac tonic, and persistent nose-bleed- 
ing is apt to improve immediately after the administration of 
digitalis, with or without iron. Thus, in a great many cases, 
anaemia is " cured by digitalis." In a similar manner digitalis 
can be utilized for the purpose of more competent oxygeniza- 
tion of the blood. When the heart is weak, and the lungs, by 
virtue of old pneumonic infiltrations, offer too great a resistance 
to an easy circulation in the pulmonary vessels, it is again digi- 
talis (or its equivalents) which facilitates the extensive contact 
of the oxygen of the atmosphere with a larger number of 
blood-cells. 

The insufficient innervation of the muscular tissue of the 
heart, stomach, and the rest, which is one of the most serious 
results of anaemia, is corrected very happily by strychnia or 
other preparations of nux. An infant a year old tolerates and 
requires one-fortieth of a grain of strychnia, or one-fifth of a 
minim of the fluid extract of nux, daily, for a long time in 
succession. These preparations may easily be combined with 
any other medicinal administrations. 

Iron is looked upon as the sheet-anchor in anaemia. It is 
mostly indicated in cases of primary uncomplicated anaemia. 
A catarrhal stomach does not bear it well ; when the stomach, 
however, is abnormal in consequence of the general anaemia, 
iron improves both the general condition and the stomach. 
In many of these cases the addition of bitter tonics is advisa- 
ble ; strychnia is perhaps preferable. Anaemia after malaria, 
dropsy from anaemia, and chronic nephritis, anaemia with 
neuralgia, anaemia with (and from) valvular diseases which do 
not result in local congestion, — mainly incompetency of the 
aortic valve, — are greatly benefited by iron. Anaemia after 
chronic diarrhoea requires great care in its use ; in most cases 
it can, or ought to be, avoided. While it is very beneficial in 



96 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

the predisposition to hemorrhage, it must be avoided in hsernop- 
tisis. It is contraindicated in inflammatory fevers, for it 
increases pulse, arterial pressure, and temperature. But in 
infectious fevers, such as erysipelas and diphtheria, it is very 
efficient. It requires good digestive powers, and, to combat 
anaemia only, no large doses. The total amount of iron intro- 
duced into the system in the daily food does not exceed much 
a single decigramme (one and one-half grains), and that con- 
tained in the blood of the adult has a total weight of three 
grammes only. Still, it is quite possible that the iron intro- 
duced into the stomach fulfils more indications than that of 
supplying hsemoglobulin. 

Of the preparations mostly in use, either officinal or other- 
wise, I have mostly employed dialyzed iron, a few minims 
several times daily, the tincture of the malate, twelve to 
thirty minims daily, and the same, or somewhat larger doses, 
of the tinct. ferr. acet. seth. and tinct. ferr. chlor. The dry 
preparations are the phosphate, one to two grains three times 
a day, and the same doses of the carbonate (saccharated). The 
latter is aptly combined with proper doses of bismuth. The 
syrup of the iodide of iron is well tolerated by the youngest 
infants ; as many drops as the baby has months may be given 
three times a day up to eight or ten drops a dose. It is well 
tolerated by the stomach, in which the iodine is freed from the 
iron and acts as an antifermentative. Besides, experience 
appears to confirm the theoretical inference that it proves its 
power as an absorbent in cases of anaemia complicated with 
glandular enlargements. The syrup of the hypophosphites 
cum ferro of the Pharmacopoeia may be given in larger doses ; 
this is the preparation which I frequently select when I mean 
to add the fluid extract of nux vomica. It is self-understood 
that I prefer the legitimate preparations of the Pharmacopoeia 
to the wares of the agents and advertisers, " physicians 5 
samples" or no. 



CONSTITUTIONAL DISORDERS. 97 

For subcutaneous administration the pyrophosphate of iron 
with citrate of sodium and the albuminated iron have been 
recommended. As ansemia is a chronic condition which re- 
quires "chronic" treatment, it is not very probable that this 
mode of employing the remedy is very available. 

The administration of iron appears to have an indirect 
effect also, which is apt to do much good. As a rule, the in- 
halation of oxygen gas, continued for five or ten minutes, in 
intervals of from an hour to two hours, seems to improve 
sanguification and metamorphosis considerably. This whole- 
some action, it always seemed to me, was most perceptible 
while iron was administered. To admit oxygen red blood- 
corpuscles are required ; it appears that the influence of iron 
on their organization and numbers renders the introduction 
of oxygen into the blood easier and more beneficial. 

Some of the worst forms of ansemia are greatly benefited 
by arsenic. They are those which result from long-continued 
inanition and slow convalescence, in which the stomach does 
not suffer ; from primary catarrh ; from chronic malaria ; from 
chronic tuberculosis of the lungs ; from chronic glandular 
swellings of a malignant type, either lymphoma or sarcoma. 
In all of these forms it is highly useful. The doses need not 
be large, but may be increased slowly. One-hundredth of a 
grain of arsenious acid, or one drop, or one and a half of 
Fowler's solution, three times a day, after meals, the latter 
amply diluted, are well borne for weeks, even months, with- 
out interruption, by a child of four or five years. In malaria, 
the remedy may be given with quinia (and iron), in other 
forms with strychnia (and iron) ; in phthisis, with digitalis. 

The gradual increase of the doses of arsenic may be effected 
in the following manner : A drachm of Fowler's solution is 
diluted with sixty drachms of water; three doses of this 
mixture are given daily. If the initial dose be one drop, give 
a teaspoonful ; the next dose is a teaspoonful + one drop, the 

7 



98 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

third dose a teaspoonful + two drops, and so on, until the 
sixty-first dose consists of a teaspoonful and sixty drops. 
Thus the original dose is gently and slowly doubled in twenty 
days. 

Children bear arsenic better than adults, and very much 
better than senile patients. Still, even they must not take it 
when they are affected with gastric disorders; nor continue it 
when in the course of treatment conjunctivitis, oedema of the 
eyelids and face, or diarrhoea make their appearance. 

2. Rhachitis. 

Many cases of rhachitis which depend on hereditary in- 
fluences might have been prevented or modified by attending 
to the parents before conception, or the mother during preg- 
nancy. For a number of their constitutional ailments make 
their appearauce in the offspring with the symptoms of rhachi- 
tis. If that precaution have been neglected, the injury in- 
flicted upon the infant cannot be completely annulled; in 
many cases, however, it can be greatly modified. Thus there 
are a great many cases of early rhachitis which are due to the 
influence of mitigated syphilis in the parents. Indeed, some of 
the microscopical bone-lesions of the two diseases, as they are 
met with in the newly-born, are difficult to distinguish from 
each other. Such cases can be greatly benefited by an anti- 
syphilitic (mercurial) treatment, which must be continued 
through a period of many months. 

Rhachitis due to, or connected with, digestive disorders de- 
mands the correction of the latter. Gastric catarrh is not 
frequently primary ; more commonly the consequence of faulty 
diet ; but it is in both cases the cause of anaemia, and of either 
insufficient or abnormal secretion of both the mucous mem- 
branes and the glands. The gastric catarrh of rhachitis is 
pre-eminently acid ; thus neutralization of the stomach is re- 
quired before every meal and between meals. Prepared chalk, 



CONSTITUTIONAL DISORDERS. 99 

calcined magnesia, bicarbonate of sodium, the several prep- 
arations of bismuth, find their proper indications in this con- 
dition. The salicylate of bismuth, animal carbon, resorcin, 
find their places, beside aromatic teas, in complications with 
fermentative processes in the intestine and excessive flatulency. 
"When the secretions of the stomach are merely insufficient, the 
addition of chloride of sodium in proper quantities will facili- 
tate the formation of hydrochloric acid. When this does not 
suffice, pepsin and muriatic acid, the latter largely diluted, will 
take the place of the physiological gastric juice; and bitter 
tonics, and alcoholic stimulants, also diluted, will stimulate a 
normal secretion. Still, the selection of a proper food forms 
the main part of the indications. The principles of infant 
feeding, both in health and disease, I have laid down in the 
first of these essays ; to them I refer ; also to my suggestions 
on the same occasion, on the selection of animal foods so 
urgently required in rhachitis. 

Malt preparations have found great favor both with the 
profession and the public. Unfortunately, the market has 
been swamped with all sorts of combinations and mixtures to 
such an extent that the confidence in their honest composition 
might easily be shaken. 

Cod-liver oil, when given pure, is a powerful addition to 
antirhachitical diet. It is safer to avoid the compounds, emul- 
sions, etc., and to rely on what is knowable. Diarrhoea is pro- 
duced by it but rarely, in the cold or cool season, — most pa- 
tients do not tolerate it quite well during the summer or on 
hot days, — but it has, besides being very nutritive, a favorable 
influence on constipation. If ever the bowels become too 
loose during its administration, the addition of bismuth, or a 
small dose of phosphate of lime, will correct the inconven- 
ience. 

Of the internal use of phosphorus I shall treat shortly. 

Though rhachitis be a general disease, and not merely one 



100 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

of the osseous system, the anomalies exhibited by the bones 
are apt to attract most attention. The changes exhibited in 
the shape of the chest, which result from the pressure of the 
atmosphere on the soft rhachitical ribs, are not liable to disap- 
pear entirely. The " pigeon-breast" — that is, the prominence 
of the sternum and (or) the costo-cartilaginous junctures — re- 
mains for life to a greater or smaller degree, according to the 
severity of the affection or the restoring power of the expand- 
ing lungs. The curvatures of the diaphyses of the long bones 
are apt to be less marked in the adult because of the extension 
which takes place during growth. If ever splints are to do 
any good they must be applied before the bones have become 
hard again; the eburnification following the softness of the 
bones after recovery resists every degree of permissible press- 
ure. The tendency to flat-foot acquired through the flabbi- 
ness of the ligamentous apparatus during the attempts of the 
child at locomotion requires straightening and sustaining by a 
shoe made strong enough to support the ankle ; scoliosis, a 
Sayre's plaster-of- Paris or a felt jacket ; the rhachitical groove 
round and above the insertion of the diaphragm, well-directed 
gymnastics of the chest; inflexible and ugly curvatures of the 
long bones, either osteoclasy (fracturing of the curved bone 
while leaving the periosteum intact, and resetting) or osteotomy 
(straightening the bone after it has undergone a cutting oper- 
ation). During the acute rhachitical process the bones will 
not only bend, but are liable to be changed in their continuity. 
It is true that genuine fractures are not quite frequent because 
of the very softness of the bones and the succulence of the peri- 
osteum. But infractions (green-stick fractures) are quite com- 
mon about the extremities and clavicles. The periosteum never 
participates in the injury; the bone is more or less bent upon 
itself; the ends are not entirely separated and are easily re- 
adjusted, but require splinting until the rhachitical process has 
terminated in general recovery. Immobilization of the entire 



CONSTITUTIONAL DISORDERS. 101 

body is sometimes required when the tendency to infraction is 
quite extensive. 

Many of the serious results of softness of the bones could 
be avoided or mitigated by precautionary measures. Babies 
in general, and those with incipient rhachitis in particular, 
must not be made to sit up before their vertebral columns are 
able to support them. They must not be carried about in an 
erect posture, nor on the same arm always. They must be 
kept and carried about in a reclining posture ; better on a hair 
pillow than on the arm until they feel strong enough to do 
without it. Thus scoliosis can be prevented. They must 
be discouraged to walk before their limbs are sufficiently 
strengthened ; thus the curvatures of the diaphyses of the 
lower extremities, which in part result from the vertical 
weight of the body on the feeble limbs, are reduced to a 
minimum. • 

Craniotabes, the rhachitical softening of the cranial bones, is 
one of the earliest symptoms of the disease. The bones which 
commenced their post-natal ossification in a normal manner 
begin to soften to such an extent that the parietal and occipital 
bones exhibit a number of spots in which the osseous tissue has 
entirely disappeared. The hair falls out in that neighbor- 
hood, the scalp is perspiring copiously, the veins get dilated, 
the bones and meninges hypersemic, and meningeal effusions 
are quite frequent. The softness of the bones results in asym- 
metry of the cranium, which is flattened by the very pressure 
of a soft pillow. 

The local hyperemia forbids the use of warm bonnets and 
feather pillows. A soft hair pillow must be so arranged that 
the head, together with the body, can be comfortably carried 
without any pressure. Consecutive brain symptoms require 
appropriate treatment. Great convulsibility demands bro- 
mides, chloral, and mild opiates, which are well tolerated in 
this condition. The perspiration requires cooling with water, 



102 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

or water and vinegar, or powdering with one part of salicylic 
acid mixed with ten parts of oxide of zinc and twenty-five of 
starch. The general treatment of rhachitis improves this 
local cranial symptom, which is quite serious. In former years 
I was in the habit of giving a good prognosis provided the 
next six or eight weeks would pass without fatal symptoms 
(convulsions, etc.). That period was generally sufficient to so 
change the general nutrition and local condition a&to restore 
a fair average of a healthy condition of the cranium and its 
contents. The experience of late years has shortened this 
period. What I suggested in a brief paper on the use of phos- 
phorus in the treatment of chronic and subacute diseases of the 
bones in the " Transactions of the Medical Society of the State 
of New York," of 1880, and in a paper on anaemia in infancy 
and childhood read before the Medical Society of the County 
of New York in 1880 (Arch, of Med., February, 1881), has 
proved a great success in other hands. For it is to Kassowitz 
that the credit of the introduction of phosphorus as the main 
remedy in rhachitis is mainly due. When, twenty years ago, 
C. Wegner fractured the bones of rabbits and fed the animals 
on minute doses of phosphorus, he found that these bones 
would heal in a much shorter time than those which were not 
so supplied. This observation induced me to employ the drug 
in all cases of subacute and chronic ostitis, Pott's disease, caries 
of the tarsus; and a great many cases led me to conclude that 
recovery was more readily accomplished under this treatment. 
Phosphorus is, by virtue of its irritating effect, when given in 
small doses, a tissue-builder, when in large doses, a tissue- 
destroyer. Thus it is that I am convinced of its tissue-building 
properties in other parts also. I may mention here, before I 
shall have an opportunity to return to the subject in extenso, 
that I have availed myself of this quality of phosphorus for 
other purposes also. It has served me well in those ominous 
cases, of purpura and similar processes, in which a congenital 



CONSTITUTIONAL DISORDERS. 103 

or acquired ill nutrition of the blood-vessel walls results in 
habitual hemorrhages. 

Kassowitz's results with the use of phosphorus in rhachitis 
are generally good. The cases in which it has rendered me 
its best services are exactly those alluded to, of craniotabes. 
A very few weeks suffice to change the condition of the cra- 
nial bones considerably, the softened parts become smaller and 
harder, and the consecutive symptoms milder. Of equal value 
it is in acute rhachitis, with its extensive acute epiphysitis, 
rapid pulse, diarrhoea, general feebleness, and symptoms of 
scurvy. 

The dose of phosphorus in these cases is from one-two- 
hundredths to one-one-hundred -and-fiftieth of a grain three 
times daily. I generally prescribe the oleum phosphoratum 
of the Pharmacopoeia, which contains one part of phosphorus 
in ten parts of ether and ninety of oil. Half a minim con- 
tains one-two-hundredths of a grain. The oil solutions must 
not be kept in a concentrated form lest they be decomposed. 
A mucilaginous emulsion is the best mode of administration, 
for which I sometimes substituted Thompson's solution. On 
no account must we be tempted to try in their place the phos- 
phates, the uselessness of which — in such cases — I have dis- 
cussed extensively in a previous paper. The hypophosphites 
of the Pharmacopoeia, with or without iron, are a better prepa- 
ration than the former. 

Laryngismus stridulus, the crowing inspiration of infants, 
is almost always connected with craniotabes, and caused by its 
meningeal and encephalic results. It consists of two stages, 
the first of which is that of paralytic apnoea, the second of a 
long-drawn and loud inspiration through the spastically con- 
tracted glottis. The causal treatment is that of rhachitis in 
general, of cranial rhachitis in particular. Before, however, it 
can accomplish a permanent effect the single attacks of, and 
the general tendency to, laryngismus require attention. For 



104 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

any attack may prove fatal, though the assertion of VogePs, 
who expresses the opinion that most cases of laryngismus are 
fatal, is grossly exaggerated in my experience, which has not 
changed in this respect since my utterances in 1871.* Beside 
the phosphorus, syrup of the iodide of iron, and other treat- 
ment, the constipation requires more than the usual attention, 
for the nerve-equilibrium is easily disturbed by a slight irregu- 
larity in any of the organic functions. To soothe its general 
vulnerability the regular administration of the bromides 
(twelve or fifteen grains daily of a mixture of the potassium, 
sodium, and ammonium salts) or a few grains daily of the vale- 
rianate of zinc are indicated. Many cases bear one-sixth of a 
grain of codeia in the twenty-four hours. These cases of ex- 
cessive irritability are quite precarious. In them the ears 
require particular attention, for the slightest (external or) in- 
ternal otitis is liable to produce convulsions. In them even 
the lancing of gums, where there is but a suspicion of local 
pruritus, may become pardonable. The attack can be cut 
short by shaking the infant, or slapping the face with a cloth 
dipped in water, or using the spark of a Leyden flask (for 
there is no time for the administration of the interrupted cur- 
rent). General convulsions following the attack, which are not 
uncommon at all, require the inhalation of chloroform or the 
rectal injection of from four to eight grains of chloral hydrate. 
The rhachitical disorders of the respiratory organs owe their 
origin to several causes. In rhachitis the heart is of average 
size, but the arteries are abnormally large. Great width of 
arteries lowers the blood-pressure. Thus it is that the mur- 
mur of the basilar artery is heard over the fontanel of the 
rhachitical infant; thus also that the muscles and bones suffer 
from insufficient nutrition ; thus, finally, that the circulation in 
the respiratory organs is slow and sluggish, with a tendency 

* American Journal of Obstetrics, etc. 



CONSTITUTIONAL DISORDERS. 105 

to produce congestion and catarrh. Other causes of the 
chronic bronchial catarrh of the rhachitical infant, which is 
so apt to become bronchitis and terminate in broncho-pneu- 
monia, depend upon the smallness of the contracted chest, 
which compresses the lungs; and the tumefaction of tracheal, 
bronchial, and mediastinal glands, which are in close lymph 
communication with the bronchial mucous membranes. There 
are but few thoroughly developed cases of rhachitis without 
them. Not infrequently can some of them be felt in the 
supra-clavicular spaces ; more commonly can they be percussed 
behind the manubrium sterni, the dulness of which is but 
partly thymic in many cases. Sometimes they can be discov- 
ered by percussion of the infra-clavicular region of the (right 
or more frequently the) left side. These glandular swell- 
ings, which point to and explain the frequent relations of 
rhachitis, scrofula, and tuberculosis with each other, are fre- 
quent appearances in the autopsies of rhachitical babies who 
finally died of the last developments of their chronic catarrh. 

This tendency to glandular swellings requires early attend- 
ance. It is here where cod-liver oil and the syrup of the 
iodide of iron are mainly serviceable. In many cases the 
addition of half a minim of Fowler's solution, administered 
three times a day, acts favorably. This is the condition of 
things in which the use of cold sponging, salt-water bathing, 
salt air, are particularly beneficial. Out-door life must be in- 
sisted upon, and there are but few reasons — mostly of a local 
character — which forbid such babies to enjoy fresh air at all 
hours of the day and night. 

Subacute or acute inflammations of the respiratory organs, 
when they have made their appearance during the chronic 
rhachitical catarrh, require, beside the usual rational treatment, 
some additional measures. More care, than in an average case 
of the otherwise healthy, must be taken lest the faltering 
strength be exhausted before the acute disease has had time to 



106 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

run its course. The sluggish circulation, depending on general 
debility and the large size of the arteries, demands the ad- 
ministration of heart tonics, — digitalis, strophanthus, sparteine, 
caffeine, or coffee, from the very beginning, and besides small 
doses of alcoholic stimulants at an early stage, the use of stim- 
ulant expectorants, such as carbonate of ammonium or cam- 
phor. There is a positive contraindication to antimonials and 
squills ; even ipecac must be avoided because of its possible 
depressing effect. 

Rhachitical constipation is mostly due to the incompetency 
of the muscular layers of the intestine and the abdoniina. 
wall. Thus purgatives must be avoided in its treatment, with 
the exception of those cases in which the accumulation of faeces 
in the bowels happens to be attended with serious consequences. 
In these an occasional dose of calomel will act both as a lax- 
ative and a disinfectant. When an acid gastric catarrh accom- 
panies the intestinal weakness, calcined magnesia in doses of a 
grain, given on an empty stomach, or before meals (never after), 
repeated several times daily, will neutralize the abnormal acidity 
of the stomach while opening the bowels. A daily enema of 
tepid water will suffice to alleviate the troublesome symptom. 
Cod-liver oil, while being administered on account of the gen- 
eral indications, has also a beneficial local effect. Pure cow's 
milk is more contraindicated in this condition than in almost 
any other. The artificial food must contain a copious addition 
of salt and sugar, and oatmeal rather than barley. Gentle 
massage of the abdomen, and strychnia, one-two-hundredths of 
a grain, three times a day, improves the muscular strength. 
The syrup of the iodide of iron, in three daily doses of a few 
drops, and the regular administration of beef preparations, will 
improve the constipation with the other symptoms; particu- 
larly when this treatment is commenced at an early period. 
For it is at an early period, generally in the second or third 
month, that this rhachitical constipation will make its first 



CONSTITUTIONAL DISORDERS. 107 

appearance. It is one of the first symptoms of protracted 
rhachitis, and is diagnosticated from what I have described 
as congenital constipation — which depends on an abnormal 
length of the sigmoid flexure — by the fact that the latter 
begins at birth. 

3. Scrofulosis. — Scrofula. 

The discrimination between scrofula and tuberculosis is 
attended with no difficulty for those who claim the bacillus 
of Koch as the pathognomonic essence of the latter. For 
all the rest, and so it was before the period of the bacillus, 
the distinction may not be quite so easy; at all events, the 
boundary-lines between scrofula and tuberculosis are not al- 
ways quite marked. But it is certain that the bacillus is 
absent in the former as long as this remains uncomplicated 
with an accidental invasion. 

We speak of scrofula in persons who exhibit a great ten- 
dency, with no apparent, or upon the slightest, provocation, to 
subacute or chronic inflammation of most tissues, mainly the 
cutis and mucous membranes, sensory organs, glands, bones, 
and joints. These inflammations are persistent and liable to 
return ; they run their course with both rapid formation and 
disintegration of the cells, equally in the erethic and torpid 
forms. Of these, the former is recognized by a frail and thin 
stature, delicate features, great intellect, blue sclerotic, and 
large pupils ; the latter, by coarse and expressionless face, 
cedematous lips and nose, congested eyes, large abdomen, 
swollen glands, and frequent cutaneous eruptions. 

It is no reproach to modern therapeutics to be mostly pre- 
ventive. So is the treatment of scrofula. Many cases of the 
disorder would not appear if our modes of thinking and feel- 
ing, our habits and laws, were not the immediate results of 
individual egotism. As long as the welfare of the common- 
wealth, both present and future, does not supersede, in the 



108 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

convictions of the many, the dictates of selfishness, there will 
be no restriction on the marriages of the scrofulous, syphilitic, 
and tuberculous, and the propagation and proliferation of 
their dangerous ailments. If the mankind of the future 
means to be healthy and happy, there must be found some 
mode of preventing hereditary influences from having full 
sway. We are no Spartans, who kill the unhealthy newly 
born, but we are to develop into men who pity those laden by 
their very parents with the eternal curse of illness, and citi- 
zens who feel responsible for the physical and intellectual wel- 
fare of the community. In the States, scrofula has been on 
the increase at a rapid pace since the immigration of the most 
abject parts of the most abject peoples of the Old World has 
been allowed to swell our numbers by the hundreds of thou- 
sands for each of the last dozen years. 

An important preventive measure is the suppression of the 
attacks of acute diseases in children, mainly the eruptive 
fevers. Upon a former occasion I have emphasized the neces- 
sity of medical (hygienic and pharmaceutical) treatment of 
every case. It is particularly measles and scarlatina which 
are liable to interfere with the subsequent normal develop- 
ment, — the former through its influence on the respiratory, 
the latter through its effect on the digestive and lymphatic 
systems, and also on the bones. The modification of a 
severe form into a milder form, and the early restitution 
of the physical functions to a normal standard, is a gain for 
life. 

Scrofula being frequently the direct result of digestive dis- 
orders, resulting either from improper food or nutriment im- 
properly given, the greatest care is to be bestowed on both 
food and the digestive organs. This is of more than the 
average importance in reference to the offspring of tuberculous 
parents. JNTo tuberculous mother must nurse her own infant. 
The selection of the wet-nurse must be the most painstaking, 



CONSTITUTIONAL DISORDERS. 109 

and the period and mode of weaning must be supervised with 
the utmost care. Afterwards amylaceous food, particularly 
potatoes, must be avoided, or given in small quantities only. 
Good milk (boiled), cereals, and meat, with the addition of 
fruit, ought to be the principal food of children up to their 
tenth or twelfth year. Stimulants must not be given except 
on proper and exceptional indications; thus tea, coffee, alcohol, 
beverages of any kind, are forbidden as articles of diet. 
Cocoa must take the place of chocolate. The best beverage 
is water. It supplies every want, and when taken in suffi- 
cient quantities is the best stimulant of tissue metamorphosis. 
In the very rare cases in which a sensitive stomach does not 
bear it well, a carbonated or (and) slightly alkaline water will 
take its place. 

Among the foods, cod-liver oil ranks high. Most children 
take it readily after a short time, and are anxious to have it. 
Thus there was no necessity of peptonizing, emulsionizing, 
or " hydroleinizing" from the point of view of the children, 
or practice. Of the reprehensibility of filling the child's di- 
gestive organs with unlimited lime I have spoken in another 
place. The oil can be taken in successive years. Its admin- 
istration ought to be interrupted during warm days and 
during the summer. Still, there are those who bear it well 
all the time. Fat children do better without it. In disorders 
of the stomach, and while the appetite is bad, also during a 
feverish disease of any kind, also during a diarrhoea, it must 
not be given. 

Preparations of malt may be administered to advantage in 
small quantities several times daily. It is self-understood 
that the multitude of preparations containing medicines will 
be left by the intelligent practitioner to the shelves of the 
corner pharmacy. 

Tea of walnut leaves was a universal remedy in scrofulous 
affections when the tastes were simpler, medicines less in 



110 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

number, and less ready money was invested in expensive 
articles. Among the poor, and in country districts, it will 
prove an admirable adjuvant. 

Among medicinal preparations it is those of iron and 
iodine which have met with most praise. The indications for 
the administration of the former are those of anaemia. Where 
this is marked, iron ought to be given, and continued for a 
long period, according to the principles and methods laid 
down in a previous chapter. Iodide of potassium, of sodium, 
and the tincture of iodine have been used. In the erethic 
form of scrofula they may do harm, and ought to be avoided. 
The same warning holds good in reference to those children 
who suffer from frequent attacks of bronchitis, which may 
already be the precursor or accompaniment of pulmonary 
tuberculosis. A sensitive stomach will not bear it. It may 
be made more digestible by the addition of a bitter tonic, and 
particularly by a few drops of tincture of nux vomica, diluted, 
with each dose. When the iodide results in bringing on the 
disagreeable or dangerous symptoms of iodism, the addition 
of chlorate of potassium to the iodide, in doses of from fifteen 
to thirty grains daily, according to age, will prove beneficial. 
The potassium (or sodium) iodide may be taken in five- or six- 
grain doses, daily, by a child of two years, fifteen grains at ten 
years, for a long period. The sodium is better tolerated, as a 
rule. The tincture must not be administered in more than 
one-drop doses, three times a day. 

The indications for the use of iodine in general are also 
valid for that of the mineral springs containing that element, 
such as St. Catherine or Kreuznach. Fat children, and those 
with oedematous swellings, glandular infiltrations, or the exu- 
dations resulting from scrofulous inflammations, are mostly 
benefited by them. 

Of phosphorus, as a tissue-builder in subacute and chronic 
inflammations of the bones, I have spoken in another connec- 



CONSTITUTIONAL DISORDERS. Ill 

tion. Its property as a stimulant of growth in general I have 
often verified in many morbid conditions. Scrofulous tissues, 
with their rapid decay and new formation, have indeed the 
character of an inflammation, with the peculiar characteristic 
of cell proliferation, which perishes speedily because it is not 
sustained by a healthy connective tissue. The latter is formed 
by the internal administration of minute doses of phosphorus, 
such as I have recommended for the above indications. Thus 
I refer to the remarks made previously on the subject, on the 
doses in which the drug is to be given, the period it is to be 
continued, and the impossibility of substituting for it any of 
its salts. Those who do not pin their faith in the treatment 
of any disease on any single remedy, but combine remedial 
measures with the proper regard to hygiene, will not be mis- 
taken in their expectations of the effects of phosphorus in the 
treatment of scrofulous disorder. I have used arsenic for the 
same purposes, and on the strength of the same indications, but 
it has appeared to me to offer less advantages in these conditions. 
A very active treatment can and must be applied to the 
lymph-bodies. Their tumefaction may be prevented in most 
cases. They swell under the influence of an irritation in the 
neighborhood. An intestinal catarrh will congest the neigh- 
boring mesenteric lymph-bodies; within a few days they are 
enlarged and hypersemic. When the local catarrh continues 
the hypersemia will result in hyperplasia, and no long period 
is required to so change the tissue as to render the induration 
unabsorbable. If the diarrhoea " of the second summer/' or 
of " teething," had not been permitted to go unchecked, these 
"scrofulous" glands would never have existed, and never 
interfered with lymph circulation and nutrition. Or a nasal 
catarrh, or a facial eczema, or one of the scalp, is allowed 
to continue and develop into a chronic condition, and the sec- 
ondary swelling of the glands round the throat and neck is 
the irrepressible result. Principiis obsta. The greatest and 



112 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

gravest consequences might easily be prevented by attending 
to their trifling causes. 

When the lymph-bodies have had time to undergo indu- 
ration, the attempt must be made to reduce them, though 
they be ever so hard or large. The frequent inunction of 
iodide of potassium ointment made with lanolin will often 
carry the point. Which preparations ought to be used, and 
to what extent the remedy, to what the massage of the parts 
is effective, have been detailed before. At the same time the 
syrup of the iodide of iron may be administered internally. 

When these measures have proved inefficient after a reason- 
able time, the indurated lymph-bodies must be removed. The 
operation is not always easy, but recovery is almost certain, 
and the protection afforded by it pays more than fully for 
every exertion on the part of the medical man, and the tem- 
porary annoyance on that of the patient. 

Diseased bones must be treated on similar principles. Un- 
less a scrofulous ostitis be superficial and within easy reach, 
the diseased parts ought to be removed with the least possible 
delay. The number of cases recovering, though after a long 
time, and sometimes with shattered general health, without 
an operation, affords no excuse for those which have been 
permitted to develop into caries, or necrosis, or pyaemia, or 
leucocythaemia. 

That the scrofulous condition requires good air and venti- 
lation may be mentioned, though it hardly appears necessary 
to do so. The children ought to be kept in the open air 
constantly. For that purpose the winters ought to be passed, 
if circumstances permit, in warmer climates. From that point 
of view the summer sea-sanitaria of our large cities, and the 
similar institutions of the civilized countries of Europe, have 
rendered valuable services. 

The skin of a scrofulous child must be kept scrupulously 
clean. But water must do more than merely that: the child 



CONSTITUTIONAL DISORDERS. 113 

must get used to cold water, and thereby accustomed to changes 
of temperatures. The principles laid down in connection with 
the bathing of the very young hold good here, and I refer to 
my remarks on the subject. Salt water is preferable to plain 
water, and sea-bathing to either. Only in the cases of those 
who suffer greatly from eczema and other scrofulous eruptions, 
water must be avoided as long as the surface is not relieved. 
Indeed, no irritation of the surface is tolerated. Thus a 
scrofulous skin ought to be spared adhesive plasters or vesi- 
catories, though the indications for their use be ever so 
tempting. 

Incidental diseases of scrofulous children require more than 
the usual care. The perishable character of all their tissues 
renders an average febrile or inflammatory disease uncommonly 
dangerous. Unexpected deaths are frequently met with in 
such cases. In them the avoidance of strong purgatives, or 
depletions, is the first commandment; in them early feeding 
and sufficient general stimulation are among the principal 
indications; in them cardiac tonics, given timely and plenti- 
fully, will save many a life that would otherwise succumb. 

4. Tuberculosis, 

In the young, as in the old, the tuberculous poison is spread 
either by mechanical transmission through cough, deglutition, 
and aspiration, or in the contiguity of tissues after having been 
developed in a given locality, or through lymph-ducts and 
blood-vessels. The latter, after having absorbed from the 
primarily invaded part, are liable to distribute the poison in a 
distant part or all over the system. Most frequently the 
primary seats of the affection in the young are the bones, 
joints, and lymph-bodies. Among the latter, those of the 
mesentery are by no means so frequently affected as they are 
still reputed to be ; those of the neck and mediastinum are 
more subject to primary infection. 

8 



114 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

The most common forms in which tuberculosis makes its 
appearance in the young are acute miliary tuberculosis, acute 
or subacute cheesy (scrofulous) pneumonia, and genuine chronic 
tubercular phthisis with cavities. The latter form is not very 
frequent, but we see it at every age. While I have met with 
but very few cases before the end of the first year, they are not 
quite rare after the sixth or eighth. It is often accompanied 
or preceded by pleurisy ; indeed, it appears probable that this 
pleurisy, with its frequent relapses, is the primary seat of 
tuberculosis in many. 

The most common form of phthisis in the young is that 
which is developed out of scrofulous pneumonia. It is a fre- 
quent result of the bronchitis and catarrhal pneumonia attend- 
ing measles and whooping-cough, and quite generally accom- 
panied with considerable changes in the glands. It is often 
seen in the lower lobes ; indeed, the upper lobes are often found 
to be the seat of induration, resulting from interstitial inflam- 
mations, which retract the corresponding part of the chest, 
exhibit diminished respiratory murmur and dulness on per- 
cussion, and may last a long lifetime without endangering life 
or health to any considerable extent. 

What I said about the mode of development of these fre- 
quent forms points at once to preventive treatment as the 
principal indication. If bronchitis, catarrhal pneumonia, 
measles, whooping-cough, and glandular diseases are frequent 
causes of tuberculosis, those primary affections must be effectu- 
ally treated. There is no bronchitis which cannot be made 
milder, many a case of catarrhal pneumonia can be shortened 
or rendered less dangerous, and most, perhaps all, cases of 
whooping-cough modified and shortened. In a former paper I 
insisted upon the necessity of treating all the self-limited dis- 
eases. The sin of omission is as grave as that of commission. 
And in my remarks on scrofula, to which I here refer, I pointed 
out the facility of eradicating the coming evil by removing un- 



CONSTITUTIONAL DISORDERS. 115 

absorbable lymphatic glands. Unfortunately, the success of 
treatment in cases of acute miliary tuberculosis is so small, 
and of chronic tuberculosis so unsatisfactory, that the indica- 
tions for preventive treatment are the more urgent. The facts 
of universal tuberculosis arising from a local source cannot be 
denied, having been proven by thousands of experimental and 
clinical observations. Now and then a case is quite demon- 
strable. A few years ago I had a little girl in my division in 
Bellevue Hospital who suffered from the most exquisite and 
extensive tuberculosis of the skin I have ever seen. She finally 
died with empyema and general tuberculosis. Coming from 
a fairly healthy family, she developed a glandular swelling in 
her right axilla, which was neglected, and permitted to break 
spontaneously and result in fistulse. From that place the 
lymphatics transported the infection, and produced extensive 
ulcerations over the chest; metastases took place to other parts 
of the body, and the child died of universal tuberculosis. It 
is an indifferent matter to investigate whether the original 
affection was tubercular already, or whether the tubercular 
character was developed afterwards. This much is certain, 
that the child need not have died if the gland which was 
primarily affected had been extirpated. 

It is unnecessary to add that tuberculosis of the bones and 
joints, so frequent in infancy and childhood, require prompt 
attention, and in many cases operative procedures. 

Among the causes of tuberculous consumption which makes 
its appearance in otherwise healthy persons, both young and old, 
the following also are given prominence by all observers of 
note : Insufficient supply or change of air, absence of exercise, 
overwork without rest or vacation, monotonous food, and per- 
sistent mental emotions. Most of these sources of disease act 
as well on the young as old, and may lead to infiltration, before 
there was any cough as yet, but anaemia, muscular debility, 
and loss of appetite only. Therefore tubercular infiltrations are- 



116 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

frequently found among the inmates of prisons, particularly 
those who have been isolated a long time, workmen in facto- 
ries, soldiers in barracks, students in seminaries, children in 
orphan asylums and large boarding-schools, those attending 
crowded public schools and overworked with their private 
,studies, besides being crippled by unwise discipline, which re- 
quires absolute immobility, and loss of time or opportunity for 
exercising. It is not very probable that the occasional prome- 
nades of the young by couples — though not handcuffed, though 
on a Madison Avenue sidewalk, though attended by the good- 
will, moral character, and Argus eyes of two elderly ladies — 
are equivalents for the free and unhampered play and de- 
velopment of the growing organs. If it be a fact that there 
is so much less tubercular disease among hunters, farmers, 
gardeners, and sailors than among factory men and women of 
all trades, school-masters, tailors, it is certain that rowing, 
skating, gymnastics, and tennis, even the so-called calisthenics, 
if practised in the open air, would expand many a child's 
chest, aerate his blood, keep his organs vigorous, and eliminate 
invading poisons. 

There are many other causes or influences creating or in- 
creasing the possibility of tubercular invasion. A considerable 
predisposition is created by the vulnerability and fragility and 
cedematous infiltration of scrofula; by the catarrh produced by 
sedentary life and foul inhalations. Koch has proved that active 
bacilli pass the stomach unmolested and invade the intestine, 
thus rendering even a primary intestinal tuberculosis possible. 

Hereditary predisposition to tuberculosis is quite frequent, 
and is transmitted even by such parents as appear to be in fair 
health. Constitutional parental disorders resulting from the 
influence of scrofula, rhachitis, and even syphilis, may become 
manifest in the children in the shape of tuberculosis. In such 
children every catarrh must be carefully watched. The pre- 
mature ossification of the costal cartilages, most frequently 



CONSTITUTIONAL DISORDERS. 117 

found about the superior part of the chest, and the consecutive 
shortening of the sterno-vertebral diameter give rise to con- 
traction of the thorax and insufficient expansibility of the (upper 
lobes of the) lungs. In such cases the aeration of the blood 
suffers at a very early date, catarrhal and inflammatory thora- 
cic diseases are liable to become dangerous, and gymnastic 
exercises are required in early childhood. 

Direct transmission from the parents to the children is prob- 
ably not frequent, but it is possible, and therefore the child 
must not share the room and bed of the consumptive. Kissing 
must be omitted under these circumstances; it may often be 
the cause of contagion, though not so frequently as, for exam- 
ple, diphtheria is transmitted in that manner. 

A consumptive mother must not nurse her infant. She is a 
greater danger than one afflicted with syphilis. Her milk is 
a positive injury, as is the milk of tubercular cows, though 
the uclder may not be diseased. Two cows out of a hundred 
are tubercular. Thus the least that can be done is to boil the 
milk intended for the nourishment of the infant. By thus 
obeying the rule which I have enjoined these twenty-five or 
thirty years, the milk can be made more innocuous than is pos- 
sible for the butter or cheese obtained from such cows. These 
rules ought to be strictly obeyed, though there be exceptions 
to the universal experience. An instance of such exceptions 
is mentioned by Biedert, than whom there is no more reliable 
observer. He reports the cases of children who were fed a 
long time on the milk of tubercular cows without being 
attacked themselves. 

Among the causes of consumption monotony of food has 
been enumerated by many. It is evident that it cannot ac- 
count for much in the cases of infants or children, whose 
habits are plainer and digestive functions more adapted to 
simpler and more uniform articles of diet. Most of these, 
while in health, are satisfied with milk, cereals, and but little 



118 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

meat. Sweet cream may be added to the milk, but more than 
a few ounces are not digested through the course of a day. 
Cod-liver oil acts mostly through its fat. During the afebrile 
condition and chronic emaciation, over-alimentation, introduced 
by Debove, may be tried to advantage, while the insufficiency 
of gastric digestion may be stimulated by the administration 
of artificial gastric juice (pepsin with muriatic acid) and mild 
stomachics (gentian, nux, diluted alcoholic beverages). Where 
exercise cannot be procured to a sufficient extent, or is contra- 
indicated by the necessity of enforcing temporary, but absolute, 
rest, massage, according to S. Weir Mitchell's plan, will take its 
place. During fever, over-alimentation has to be stopped; it 
deranges digestion and slowly increases the fever. Alcoholic 
stimulants will at that time often take its place to advantage. 
While they do not act well in the general erethistic condition 
of certain over-irritable natures, with over-sensitive hearts, and 
in haemoptysis, they are good stimuli for the general system, 
diminish perspiration, and act favorably in diarrhoea. 

In the treatment of tuberculosis no single factor is beneficial 
by itself. The quality of the air alone will not cure the sick 
any more than a certain mixture of salts and water in a mineral 
spring, or some known chemical relation of albuminoids and 
carbon-hydrates in an article of food. Insufficient clothing and 
bedding, unheated rooms, draughty halls, indigestible food, 
strong coffees and teas, hot cakes and cold drinks, late hours, 
lively hops, brass instruments and pianos disturbing midnight 
rest, kill as many, in proportion, in Colorado, Florida, Southern 
France, and Italy, as in New York. Unfortunately, we know 
too well that our patients believe they have done enough for 
their physician (or themselves ?) when they have followed his 
advice to change climate. In this respect, too, it is true that 
those who speed over the sea are changing their sky, but not 
their spirit.* It must never be forgotten that the change of 

* " Cceluni non animam mutant qui trans mare currunt." 



CONSTITUTIONAL DISORDERS. 119 

climate is mostly a negative remedy, and cannot be expected 
to offer more than the possibility of favorable external circum- 
stances. 

Moist air is a better conductor of warmth than dry air. 
Thus loss of temperature is more rapid in moist air than in 
dry air. Dry air, therefore, may be very much cooler, and 
is still better tolerated in spite of its lower temperature, and 
affords more protection. Haemoptysis appears to be a frequent 
occurrence at the times and seasons of increasing atmospheric 
moisture (spring). According to Rohden's researches a rapid 
increase of the percentage of water in the blood is frequently 
sufficient to produce a hemorrhage. Thus the drinking of 
large quantities of water ought to be avoided, and no residence 
be selected for a patient subject to haemoptysis where the atmos- 
phere is very moist. Dry altitudes such as those of New 
Mexico have given me good results in pulmonary hemorrhage. 
At all events, no place must be selected where the percentages 
of moisture in the air are liable to change rapidly. The 
uniformity of an insular climate, while benefiting the average 
case of phthisis, is, therefore, not so dangerous to those who 
have bled from their lungs. Still, dry air and a higher scale 
of the barometer are preferable. 

The diversity of opinions in reference to the climato-thera- 
peutics of phthisis resulted from the circumstance that the 
indications were not distinctly understood. Neither cold nor 
warm, neither dry nor moist, air by itself is a remedy. Warm 
air does not cure, but it enables the patient to remain out of 
doors. The temperature must be uniform, sudden currents of 
air avoided, and the atmosphere free of microphytes. At an 
altitude of sixteen hundred feet their number is greatly re- 
duced (Miquel), there are but few at a height of two thousand 
six hundred feet (Freudenreich), very few at six thousand, 
absolutely none at twelve thousand feet, provided the parts 
are not, or but little, inhabited. Over-population of elevated 



120 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

villages and cities diminishes or destroys their immunity. In 
the factories of the Jura Mountains, with a great working 
population, at an altitude of three thousand five hundred feet, 
tuberculosis is frequent. 

Protection against sudden gushes of wind and rapid changes 
of temperature is an absolute necessity. The elevated valleys 
or rather recesses of mountains (Colorado) deserve their repu- 
tation in pulmonary diseases. Davos is dusty, windy, and 
exposed to frequent changes of temperature during the sum- 
mer, and must not be advised for that season. Woods are 
warmer in winter, cooler in the summer; so is the ocean. 
Both, therefore, deserve well their reputation in the chronic 
ailments of the respiratory organs. 

Not the thinness of the atmosphere, but its purity, is the 
requisite, and a high percentage of ozone. The latter is de- 
veloped under the influence of intense light, the presence of 
luxuriant vegetable growth, particularly of evergreen trees 
(Terebinthinacese), and the evaporation of large sheets of water. 
Thus ozone is found on moderate or high altitudes, in needle- 
wood forests, and near or on the ocean. 

In the general hygienic treatment of tuberculosis the skin 
requires particular attention. Sudden changes of temperature, 
which strike the surface suddenly and work their effects on 
internal organs by reflex, — " colds/' — in spite of the modern 
superciliousness of some who deny any pathological change 
unless the exclusive work of bacteria, will always hold their 
places in nosology. The skin must be both protected and 
hardened. Wool, or wool and cotton, must be worn near the 
skin, the feet particularly kept warm, no wet or moist feet 
permitted, undergarments changed according to season and 
the alternating temperatures of days or weeks, and every night 
and morning. It is of the greatest importance to impress 
upon the minds of the very poorest that they must not wear 
during the day what they have slept in. Still, while protec- 



CONSTITUTIONAL DISORDERS. 121 

tion is to be procured anxiously, vigor and strength is to be 
obtained by accustoming the surface to cold water. The daily 
morning wash may be warm in the beginning, and become 
gradually cooler; alcohol added to the water in the beginning 
(alcohol alone is unpleasant by its withdrawing water from the 
tissues), or salt always. The temperature of the water being 
gradually diminished, the same treatment can be continued 
during the winter, with a pleasant sensation of vigor. The 
subsequent friction with coarse bathing towels sends a glow 
over the surface and through the whole body ; it is desirable 
that, as much as possible, the patient perform it himself. The 
easiest way to start the habit is by washing, a short sponge- or 
shower-bath will take its place soon, and a cold plunge will 
be borne even by the weak afterwards. 

It has become fashionable with many to feign a contempt 
for internal medicines in the treatment of tuberculosis, pul- 
monary and otherwise. I am glad I cannot share their 
opinions. Thus, for instance, I look upon arsenic as a power- 
ful remedy in phthisis. It was eulogized as early as 1867 by 
Isnard, in a monograph, for its effect in both malaria and con- 
sumption, in both of which he explained its usefulness through 
its operation upon the nervous system. He claimed that sup- 
puration, debility, emaciation, vomiting, diarrhoea, and consti- 
pation would improve or disappear under its administration. 
The doses of arsenious acid used by him in the cases of adults 
amounted to from one to five centigrammes (one-sixth to five- 
sixths of a grain) daily. 

Arsenic is certainly a powerful remedy. It is known to act 
as a poison and a strong caustic. It prevents putrefaction, 
though as an antiseptic it ranks even below salicylic acid. It 
acts favorably in malaria, chronic skin-diseases, maladies of 
the nervous system, and has considerable, and sometimes un- 
expected, effects in the treatment of lympho-sarcoma and sar- 
coma. It is also said to improve sexual desire and power, 



122 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

and in animals physical courage. Thus there is a variety of 
effects the intrinsic nature of which may be found, uniformly, 
in the action of the drug on the function and structure of the 
cell, which, though varying in different organs, has the same 
nutritive processes. Arsenic has a stimulating effect on cell- 
growth. In small and frequent doses it stimulates the devel- 
opment of connective tissue in the stomach, in the bone and 
periosteum, everywhere; in large doses, by over-irritation, it 
leads to granular degeneration. Like phosphorus, arsenic 
builds in small doses, destroys in large ones. By fortifying 
the cellular and all tissues, both fibres and cells, it enables them 
to resist the attack of invasion, both chemical and parasitic, 
or to encyst or eliminate such enemies as have penetrated them 
already. Thus it finds its principal indication in the peculiar 
fragility of the blood-vessel walls resulting in pulmonary 
hemorrhage. 

The doses must be small. A child a few years old may 
take two drops of Fowler's solution daily, or a fiftieth or 
fortieth of a grain of arsenious acid for weeks or months in 
succession. This amount may be divided in three doses, 
administered after meals, the solution largely diluted. There 
is no objection to combining it, according to necessity, with 
stimulants, roborants, or narcotics, and to giving it for an 
indefinite period, unless the well-known symptoms of an over- 
dose — gastric and intestinal irritation and local oedema — make 
their appearance. But they seldom will, particularly when 
small doses of opiates are judiciously added to them. In 
almost every case, perhaps in every one, it is desirable to 
administer it in conjunction with digitalis. 

In the vertebrate animal, digitalis increases the energy of 
the heart-muscle and its contraction ; thereby it increases 
arterial pressure and diminishes the frequency of the pulse. 
By increasing arterial pressure it favors the secretion of the 
kidneys, improves the pulmonary circulation, empties the veins, 



CONSTITUTIONAL DISORDERS. 123 

thereby accelerates the flow of lymph and the tissue fluids, and 
exerts a powerful influence on the metamorphosis of organic 
material, — that is, general nutrition. Besides, what it does for 
the general circulation and nutrition it also accomplishes for 
the heart-muscle itself. The blood-vessels and lymph circula- 
tion of the latter are benefited equally with the rest. Thus 
digitalis, while being called a cardiac stimulant, contributes 
largely to the permanent nutrition and development of the 
organ. This effect is not only of vital importance for the 
economy of the system on general principles, but an urgent 
necessity in view of the fact that there appears to be a relative 
undersize of the heart, either congenital or acquired, in cases 
of phthisis; and there is certainly such a predominance of the 
size of the pulmonary artery in the young, particularly over 
the aorta, that the normal succulence of the lung becomes 
pathological quite readily when the insufficiency of the heart- 
muscle tends to increase low arterial pressure within the dis- 
tributions of the pulmonary. The selection of the prepara- 
tion to be administered is not always an indifferent matter. 
The infusion and the tincture are not always well tolerated by 
the stomach; digitalis, not being a soluble alkaloid but a 
glucoside, is not always reliable in its effects, and not of equal 
consistency and strength ; a good fluid extract, or the extract, 
are borne well and may be taken a long time. A child a few 
years old may take about two minims of the former daily, 
more or less, for weeks and months, or its equivalent in the 
shape of the extract (two-thirds of a grain daily) ; the latter 
can easily be given in pills, to be taken in bread, or jelly, and 
combined with any medicines indicated for special purposes, 
such as narcotics, or mix, or arsenic, or iron ; the latter to be 
excluded in all feverish cases, or in all cases as long as there is 
fever. As long as there is no urgent necessity for a speedy 
effect, digitalis will suffice by itself; as a rule, it does not 
operate immediately in those small doses. The addition of 



124 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

strophanthus, or sparteine, or caffeine, all of which are speedily 
absorbed and eliminated, and exhibit their effect rapidly and 
without the danger or inconvenience of cumulation, will prove 
advantageous in many cases. 

Other medicines have been used in great numbers. Specifics 
have been recommended, and symptomatic treatment been 
resorted to. The success of the latter depends on the judg- 
ment of the individual practitioner. No text- book or essay 
can teach more than general principles and their adaptation to 
the average case, and the measures to be taken in a number of 
exceptional occurrences. The indications for the use of nar- 
cotics, stimulants, expectorants, and febrifuges will change 
according to the cases and their various phases and changes. 
In every case the necessity may arise for antipyrin, antifebrin, 
phenacetin, salicylate of sodium, or quinia. It may be neces- 
sary to decide the question whether the administration is to be 
made through the mouth, rectum, or subcutaneous tissue, or 
how their effects are to be corrected or combined. I have 
often found that a hectic fever would not be influenced by 
quinia, or by antipyrin, or salicylate of sodium. But the 
combination of the first with one of the latter would frequently 
have a happy effect. 

The change in our pathological views, or rather the addition 
of a new factor in our etiological knowledge, has directed our 
attention to the antisepsis of the respiratory organs. To destroy 
bacteria is not necessary in order to make them relatively harm- 
less. It is impossible to kill the bacillus without killing the 
normal cell, but very mild antiseptics suffice to stop the effi- 
ciency and proliferation of the parasite. Thus we can hope 
that the future will teach us to reach the destructive process 
in the lungs. It is quite possible that the inhalation of hydro- 
fluoric acid will not prove more beneficial than the rectal in- 
jection of sulphide of hydrogen, but the internal use of creasote 
(one to three minims to a child daily) and terebene (two to four 



CONSTITUTIONAL DISORDERS. 125 

minims every two or three hours) and the inhalations of turpen- 
tine, eucalyptol, menthol, and many others, appear to rouse our 
hopes for a future effective treatment. Much more than hopes 
we cannot have at this moment. But it is useless to despair, 
both passively and actively. For the present, however, it is 
a desperate activity which tempts an enterprising hero of the 
reckless knife to cut away a part of a lung which is the seat of 
a general and disseminated process. 

Among the localizations of tuberculosis in children that of 
the larynx is not frequent, but it is met with. According to 
Heinze, laryngeal tuberculosis is not produced by contact, but 
through the medium of the blood. But the expectorated 
masses are undoubtedly a frequent cause of the local infection, 
and as a rule the larynx is invaded rather than the lungs. 
Beside nodulated inflammatory swellings in the mucous mem- 
brane, submucous tissue and glands, sometimes even between 
the muscles, there are small granulations and ulcerations on 
the cords, with universal catarrh, oedema, and phlegmonous 
destruction. The symptoms are those of catarrh and ulcera- 
tion, and depend on the locality and severity of the lesion. 
In some cases the diagnosis of pulmonary tuberculosis could 
not be made in the beginning, and that of the local affection 
was based on the duration of the ailment, the persistence of 
the fever, and steady emaciation. At first the laryngoscopy 
examination revealed catarrh only, and but later ulceration 
and infiltration. The local treatment is that of the catarrh, — 
inhalation of warm vapors, steam, turpentine, carbolic acid, 
muriate of ammonia; poultices round the neck; opiates at 
bedtime. The spray with lactic acid and the application of 
iodoform have served me less well than a daily spray of a 
solution of one part of nitrate of silver in two or five hun- 
dred parts of distilled water. Stronger solutions are rather 
harmful. The pain produced by ulcerations located on the 
epiglottis and arythenoid cartilages is somewhat relieved by 



126 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

the application (brush or spray) of bromide of potassium, 
morphia, or cocaine, or an appropriate mixture of two or three 
of them. 

The air around patients suffering from laryngeal phthisis 
may be moist; but it is a mistake to believe that it must be 
warm. Cold air is warmed before it enters the larnyx and 
lungs, provided it enters the respiratory tract through the 
nares. Only when it is admitted through the mouth it re- 
mains somewhat cool when reaching the larynx. Thus the 
nares must be kept as normal as possible, and competent, no 
matter with what difficulties : nor will open windows inter- 
fere with the comfort of the patient, provided that draught 
is avoided. That can be easily accomplished by screens or 
otherwise. 

Ulcerations of the tongue and pharynx are painful some- 
times to such an extent as to require frequent attention. A 
well-directed spray, as mentioned before, of one part of nitrate 
of silver in two hundred of distilled water (glass to be of 
neutral, blue, or black color), administered once a day, will be 
found serviceable in average cases. Some are so bad as to in- 
terfere seriously with deglutition. I have been obliged to use 
a cocaine spray before every meal. 

Tubercular ulcerations of the intestines may descend to the 
rectum ; in that case the local symptoms, and mainly the 
tenesmus, may be alleviated by warm injections containing 
gum acacia or bismuth, with or without opiates. Food and 
drink must be warm ; bismuth may be given in doses of from 
two to ten grains every hour or two, so as to form a protection 
to the sore intestine. Tannin I have not seen to do much 
good. Naphthalin sweeps the whole length of the tract and 
acts favorably as a disinfectant. I have seen almost imme- 
diate improvement after its use. From four to ten grains 
may be given daily. Now and then the stomach rebels 
against it ; in that case, resorcin, in doses of from one-fourth 



CONSTITUTIONAL DISOEDEES. 127 

to one grain, in a powder or in solution, may be given for the 
purpose of disinfection from three to eight times. Though it 
be very soluble, it certainly is effective to a certain extent. 
All of them may be combined with bismuth, or lead, or 
opium. Hydrargyrum bichloride cannot be relied upon for 
any effect in the lowest parts of the intestinal tract because of 
its great solubility, the necessity of great dilution, and its 
ready absorbability. 

Fistula in ano is a rare occurrence in children under all cir- 
cumstances. I remember but two cases in tuberculous girls of 
about ten years. No matter whether they be accidental com- 
plications, or the tubercular poison (bacilli) be conveyed to the 
parts through the circulation, or the fistula be the result of the 
presence, in the faeces, of bacilli, and their action on defective 
epithelium, practice has changed entirely during the last dec- 
ade. The axiom that fistula in a consumptive patient must 
not be interfered with has given way to a more rational theory 
and sounder practice. The sooner they are operated upon and 
treated the better. 

Pulmonary hemorrhages are not of so frequent occurrence 
as in adults, but I have observed them in children of from 
three to eight years. A single instance of hsemoptysis in a 
girl of eleven years proved fatal by suffocation. The appli- 
cation of a lump of ice or an ice-bladder over the locality of 
the hemorrhage acts favorably, either through the direct influ- 
ence of the cold temperature or the reflex contraction of the 
bleeding vessels. The subcutaneous injections of the fluid ex- 
tract of ergot, or ergotin in glycerin and water, are very apt to 
give rise to induration or abscesses ; thus it will be left to the 
practitioner to decide in an individual case whether that risk 
may be taken. Sclerotinic acid has been recommended for the 
same purpose. A syringeful has been injected hourly of a solu- 
tion of one part in five of water. It is claimed that no local 
injury is done by it, but it is painful, and has been corrected 



128 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

by the addition of morphia. The latter may be given inter- 
nally also for the purpose of relieving the patient's symptoms, 
both objective and subjective. If it cannot be swallowed well, 
the proper quantity of Magendie's solution, not diluted in 
water, is readily absorbed through the mucous membrane of 
the mouth or throat. The internal administration of ergot 
may be supported by that of mineral acids and digitalis. Of 
the latter, a single dose of from two to five grains, or its equiva- 
lent, acts well. The dilute sulphuric acid is both efficient and 
palatable ; ten or fifteen drops in a tumbler of (sweetened) 
water will be readily taken to advantage. Acetate of lead, in 
doses of one-sixth to one-half of a grain, every hour or two, 
according to age and the severity of the case, is preferable to 
tannin; it can be given with morphia or digitalis, or both. 
The patient requires absolute rest and encouragement, and 
must be induced to make long, forcible inhalations, and told 
to suppress the cough as much as possible. To relieve it 
opiates may be required. For the purpose of stopping hemor- 
rhages the inhalation of the sesquichloride of iron (1 to 100) 
has been recommended. As it was not expected to enter the 
bronchial tubes, its effect was presumed to be by reflex action. 
I have tried it a number of times, like many others, but can- 
not sufficiently recommend it. 

Night-sweats are not uncommon in the tubercular phthisis 
of children of from five to twelve years of age. They are 
favorably influenced by the same remedies which are apt to 
relieve the adult; such are the sponging with vinegar and 
water, or alum, vinegar, and water. A powder of salicylic 
acid three parts, oxide of zinc ten, and amylum ninety, or 
salicylic acid three, amylum ten to twenty, and talcum eighty 
or ninety, dusted over the suffering surface, is quite beneficial 
and soothing. For internal administration the dilute sul- 
phuric acid, ten or fifteen drops in a tumblerful of water, is 
found enjoyable by a great many. A single dose of atropise 






CONSTITUTIONAL DISORDERS. 129 

sulphas (one-three-hundredth to one-hundredth of a grain) at 
bedtime, or agaricin (one-fiftieth to one-twentieth of a grain), 
or duboisin (one-hundredth to one-fiftieth of a grain) will suc- 
ceed in bringing relief. Where there is an indication for 
opium, it may be combined with any of them. When the 
digestion is good, a fair dose of quinine (three to six grains), 
with or without extr. ergot, (the same dose), or extr. ergot. 
fluid, (one scruple to half a drachm), deserves a trial when for 
some reason or other the above remedies are discarded. 

5. Syphilis. 

The nutrition of an infant suffering from hereditary syphi- 
lis is attended with great difficulties. Many of the mothers 
who contracted syphilis either before conception or during ges- 
tation are anaemic in addition to their constitutional ailment ; 
thus their milk is liable to be both incompetent and danger- 
ous. The former class, however, is not very numerous, for 
women syphilitic before conception are apt to miscarry and 
have no living children. The latter class (those who con- 
tracted syphilis during their pregnancy) is not quite frequent, 
fortunately; but still the question will come up now and then 
whether the baby of a woman who acquired syphilis in the 
course of her pregnancy should be nursed by her or no. The 
theoretical answer to this question has been this, that the baby 
may be permitted to nurse if it have been infected already, but 
must not be put to the breast if still healthy. That answer is 
no answer ; for in most cases of such acquired syphilis, and 
even in most of those of hereditary syphilis (derived from a 
father syphilitic before conception), the first symptoms of the 
disease in the infant are visible after some, or many, weeks only. 
Thus, nobody knows whether the newly-born is infected or 
not. If such a baby be puny, feeble, and in poor general 
health, nobody would have the courage to deprive it of its 
mother's milk. Artificial feeding would be a death-warrant. 

9 



130 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

Thus, such a baby ought to be nursed by its mother, and, if 
exceptions be permissible in favor of the puny, and the puny 
be expected to thrive on its mother's milk, the vigorous baby's 
chance will be the better. Therefore I certainly advocate the 
baby's nursing at the breast of the mother who acquired syphi- 
lis during pregnancy, no matter whether the symptoms of the 
disease be visible in the baby or not. Meanwhile, both mother 
and baby must be subjected to a thorough and prolonged anti- 
syphilitic treatment. 

The same baby must not be put to the breast of a healthy 
wet-nurse, no matter whether symptoms have made their appear- 
ance in the baby or not ; or whether the baby has been sub- 
jected to an antisyphilitic treatment or not. For the nurse must 
not be exposed under any circumstances, without at least having 
been made fully aware of the risk she is running. 

The mother of a baby infected with hereditary syphilis is 
herself either syphilitic or not. If the latter, she is immune 
as regards her infant, — that is, she will not be infected by her 
nursing syphilitic infant. In both cases she must and may 
nurse. For if syphilitic herself, she will not render the case of 
her infant more serious; if not, she cannot transmit a disease 
she has not herself. In neither case can she be infected by the 
diseased infant. In either case, both mother and child must 
be treated. 

In no case must a baby either syphilitic or suspected of 
syphilis be put to the breast of a healthy wet-nurse. Syphilis 
contracted through the , infection of the nipple is liable to be 
as destructive as that which attacks physicians through their 
fingers. Such a wet-nurse must be forbidden to nurse alto- 
gether, or permitted only with a full knowledge of the circum- 
stances, and directed, if she accept a place after all, to nurse 
through an artificial nipple. Meanwhile, the syphilitic or sus- 
pected baby must undergo an antisyphilitic treatment. If only 
suspected, but for good reasons, the treatment must not be 



CONSTITUTIONAL DISORDERS. 131 

postponed until positive symptoms may have made their ap- 
pearance. For mercurial treatment is a less grave interference 
in the young than in the old, and nothing can be more repre- 
hensible than the opportunity given to constitutional syphilis 
to obtain full sway. 

From what has been said of the many contraindications to the 
infant being brought up at the breast, it follows that artificial 
feeding must often be resorted to. This circumstance impairs 
the prognosis considerably, and claims the best knowledge and 
soundest judgment of the well-informed practitioner. 

Preventive treatment is required both on the paternal and 
maternal side. Syphilitic endometritis leads mostly to mis- 
carriage ; when the embryo or foetus survives, the newly-born 
exhibits syphilis at once. Women infected during pregnancy 
may, or may not, infect the offspring, according to the time of 
their own primary and secondary symptoms. In all of these 
cases a thorough and protracted, antisyphilitic treatment is 
required. For practical reasons, for women with habitual 
abortion, where the diagnosis cannot be positively made, I 
advise and practise mercurial treatment. Most cases of he- 
reditary syphilis, however, are derived from the father. It 
is he who has to undergo a strict and effective treatment for 
the purpose of extinguishing the calamitous disorder. 

The medicinal treatment of hereditary syphilis requires the 
several preparations of mercury, in many cases iodides also. 
Their indications, modes of administration, and doses depend, 
to a great extent, on the locality or organ affected, whether 
skin, mucous membrane, subcutaneous tissue, lymphatic glands, 
muscles, bones, the viscera of the thoracic or abdominal cavi- 
ties, the nervous system, or the sensory organs ; and on the 
time at which the first symptoms become perceptible. In the 
majority of cases this takes place between the fifth and eighth 
weeks of life. Then the nose, lips, and anus exhibit rhagades; 
these fissures are apt to be quite painful ; the skin is getting 



132 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

covered with roseola, the palm of the hand and sole of the 
foot with efflorescences ; the complexion becomes sallow with- 
out being uniformly so at all times, for indeed changes and a 
certain degree of intermission are observed. After a while 
maculous, squamous, and papulous eruptions make their ap- 
pearance, pustules and vesicles spring up and terminate in 
ulcerations, gummata appear in the skin. This form permits 
of a fair prognosis, particularly in the cases of infants reared 
at the breast. The treatment can be carried out slowly and 
systematically. 

It consists in the internal administration of calomel ; doses 
of from one-twentieth to one-sixth of a grain can safely be 
given three times a day, for months in succession. If in any 
case diarrhoea were to set in, and no fault be found in the 
food administered, or the condition of the digestive organs 
impaired by other causes, from a twentieth to a twelfth of a 
grain of Dover's powder may be added to each dose. 

Other mercurial preparations have been recommended, the 
bichloride and the cyanide in doses of from a one-thousandth 
to a three-hundredth of a grain several times daily. As these 
pages, however, are being written for practical guidance, and 
not for the elaboration of the history of the therapeutics of 
infant syphilis, I can but advise the use of calomel as effective 
and sufficient. The use of the blue ointment has been eulo- 
gized under the impression that the internal administration of 
the drug might lead to digestive disorders; as inunctions made 
in the usual way were found to irritate the skin (oleates are 
objectionable for that reason alone), it was recommended to 
apply it to a sheet of soft leather surrounding the knee, and 
secure its slow embrocation by the spontaneous movements 
of the baby's extremities. Thus the treatment is left to a 
great extent to the patient, and the actual dose cannot, to say 
the least, be determined upon or even estimated. When the 
skin is badly affected, from ten to twenty-five grains of the 






CONSTITUTIONAL DISORDERS. 133 

bichloride of mercury may be added to the daily bath of the 
infant. This external treatment also can be continued for 
weeks. 

A similar treatment is required in those cases in which an 
infant or child (in him in larger doses) has acquired syphilis in 
one of the many ways in which the disease can be contracted. 
The ritual sucking out of the circumcised prepuce has given 
rise to syphilis as it has produced tuberculosis; syphilitic 
nipples of a mother or nurse, vaccination, kissing, the brush- 
ing of the throat with infected instruments, in older children 
sexual contact, are causes of syphilis much too frequently. 
This acquired syphilis of infancy and childhood is apt to run 
a swifter and more deleterious course than the same disease in 
most adults. Therefore it may become necessary to add to the 
above treatment such methods as have proven most effective 
and speedy in the most urgent cases of hereditary syphilis. 

These urgent cases run a different course from those briefly 
sketched above. In many the diagnosis of hereditary syphilis 
can be made immediately after birth. General pemphigus of 
the surface of the newly-born is not a symptom of syphilis, but 
localized pemphigus of the palms of the hands and the soles of 
the feet is. It is but seldom the only symptom, though it re- 
quires often a close observation not to overlook the affections 
of internal viscera and the bones. The latter are often the 
seat of syphilitic disintegration ; in the costo-cartilaginous 
junctures Wegner has studied the changes worked by syphilis 
long ago. Liver, spleen, pancreas, and lungs exhibit two dif- 
ferent changes, either gummata or intestinal proliferations of 
the connective tissue. In the liver these are mainly met with 
along the blood-vessels and bile-ducts, and capable of pro- 
ducing jaundice, and even total and permanent obstruction of 
the ducts in the foetus or the newly-born. An early tumefaction 
of the spleen was the first prominent symptom in one of my 
cases. Twice I have seen both testicles the seat of syphilitic 



134 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

tumors in the newly-born. The blood-vessels suffer at an 
early period. The syphilitic arteritis, first described by Heub- 
ner, gives rise to congestions and hemorrhages (petechia? and 
purpura) on skin and serous membranes, in the intestines and 
kidneys, in the cranium, and in the thymus gland. And many 
early brain symptoms and sudden deaths of the newly-born 
are due to intracranial hemorrhages, oedema, and softening from 
the same causes. Nor have the sensory organs of the newly- 
born any immunity. In one, C. S. Bull has met with iritis 
and choroiditis. 

These are the cases in which the systematic calomel treat- 
ment is insufficient. In them it is of the utmost importance 
to get the system immediately under the influence of mercury. 
With or without the internal treatment subcutaneous injections 
of mercury must be made at once. The subcutaneous injec- 
tions of calomel, which I have tried, like many others, in the 
adult, have given me, contrary to many assertions of its spon- 
sors, so much trouble in the shape of abscesses or indurations, 
that I cannot bring myself to recommend them in the newly- 
born, with its spare connective tissue. But a solution of from 
one to two grains of bichloride of hydrargyrum in an ounce of 
distilled water is quite innocuous. It can be safely injected once 
or twice daily, in doses of from a one-hundredth to one-fiftieth 
of a grain. That treatment I have followed in many an urgent 
case more than a dozen years, and can safely recommend it. 

When the bones and glands suffer at an early period, the 
mercurial treatment ought to be combined with the administra- 
tion of the iodides. Potassium iodide may be given to the 
infant in doses of from five to twenty grains daily. Under 
all circumstances, the treatment has to be persisted in many 
months after the disappearance of the very last symptoms. In 
spite of that the constitutional disorder may break out again, 
either in its original form, or as an osteitis only, leading either 
to caries or to sclerosis ; or as a cerebral or spinal affection. 



CONSTITUTIONAL DISORDERS. 135 

Syphilitic arteritis, meningeal exudation, or gummatous tumor 
may lead to ptosis, nystagmus, facial paralysis, hemiplegia, 
hemichorea, or idiotism ; to myelosclerosis or transverse mye- 
litis. A syphilitic inflammation of the labyrinth with Me- 
niere's symptoms has been observed in a girl of five years 
by Knapp, and interstitial keratitis appears to result from 
syphilis quite often. In all such cases the energetic treatment 
with mercury and iodides combined has to be resumed, and 
continued for an indefinite period. But it has often appeared to 
me that syphilis will do more than produce those unmistakable 
symptoms. There are many cases of "scrofula/' chronic 
lymphadenitis, and rhachitis which — with no other causes to 
account for them — appear to point to previous syphilis not 
completely extinguished. In a number of my own cases I 
have personal knowledge of such a history. Such cases do not 
only explain the fact that many old authors recommended 
mercury in " scrofula" and " rhachitis," but also that there are 
some in which that treatment is indispensable. But lately I 
had to deal with chronic cervical adenitis, mainly of the left 
side, and pulmonary infiltration of the left upper lobe, in a 
baby of two years. They resisted the usual treatment for more 
than a year before the suspicion of its syphilitic nature was 
roused and the history of the disease elicited. Six weeks of 
a mercurial and iodide treatment have worked a miraculous 
change in the local and general condition. 

6. Hemorrhagic Diathesis. 

Under this head I propose to treat of purpura, the hemor- 
rhagic disease of Werlhof, scurvy, peliosis rheumatica, and 
haemophilia, because of their similarity of symptoms and their 
— to a certain extent — uniform anatomical cause. Among 
them all, the first, with its wide-spread petechias and subcutane- 
ous and cutaneous hemorrhages, is most frequently mentioned. 
It results from all causes interfering with general nutrition. 



136 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

and particularly that of the blood-vessels. Among them are 
poverty, uninhabitable dwellings, chronic gastro-intestinal ca- 
tarrh, dysentery, typhoid fever, diabetes, miliary tuberculosis, 
pneumonia, diphtheria, scarlatina, and measles. The complica- 
tions with hemorrhages from the nose, stomach and intestines, 
kidneys, into the brain and retina, are denominated Werlhof 's 
disease. The diagnosis of " scurvy" requires bleeding from 
the gums, " peliosis" complications with "rheumatic" pain and 
swelling of the joints, and haemophilia the hereditary tendency 
to bleeding of (mainly) the male transmitted through the 
female. 

The alleged defective condition of the blood does not explain 
the hemorrhagic tendency. No blood, though ever so thin, pene- 
trates a healthy blood-vessel wall. Hydrsemia by itself does not 
produce bleeding without an impaired condition of the tissue of 
the blood-vessel ; thus it is that the same degree of ansemia in 
women may result in metrorrhagia in one, in amenorrhea in the 
other. Infants are peculiarly liable to bleed, because in them 
the blood-vessel tissue is still undeveloped ; the embryonic con- 
dition extends into early infant life, and gives rise to the fre- 
quent hemorrhages into the brain, meninges, and other serous 
membranes. When morbid influences are added to this physi- 
ological predisposition, the result is easily comprehended. 

The treatment is to a great extent preventive. The social 
condition of a large part of the population is a main cause and 
ought to be improved. Thus the successful treatment depends 
largely on the prosperity of all, and is another proof of what 
ought to be considered a fact, that medical and social questions 
and aims are frequently identical. Zymotic disorders and 
eruptive fevers must be treated with a view of sustaining the 
strength of the system and the vigor of circulation. The 
heart's action must be watched constantly, and cardiac tonics 
given before heart-failure sets in. The dietetic treatment of 
these diseases is at least as important as their medicinal man- 



CONSTITUTIONAL DISORDERS. 137 

agement. In this way hemorrhagic diathesis is kept off, as 
well as exhaustion. 

Medicines can accomplish a great deal, but ergot less than 
it is often credited with. In these conditions I have often met 
with its untoward influence on digestion, and but rarely with 
a favorable influence on the hemorrhagic deposits or processes. 
Iron also does not appear to yield desirable results ; among 
its preparations the tincture of the chloride is perhaps the best; 
the tincture of the malate and the liquor of the albuminate are 
well tolerated. Digitalis has a favorable effect on the heart's 
action ; an infant of a year may take the equivalent of from 
one to four grains daily for some days, two grains daily after- 
wards. With it maybe combined strychnia; the same baby 
may take a fiftieth of a grain daily. As relapses are quite fre- 
quent, the invigoration of the blood-vessels is the main object 
in view. From one to three drops of Fowler's solution, 
largely diluted, may be given every day for a long time. 
Better still is phosphorus, the method of whose administra- 
tion, and the doses of which, have been detailed in a former 
paper. Lead and tannin have not satisfied me at all. Local 
hemorrhages, when accessible, will require the application 
of ice, or compression of the bleeding vessel. The success 
of the preventive treatment of haemophilia will be rather 
doubtful as long as the individual is not controlled by the 
community in regard to the demands of public health. The 
daughters of hemophilic families ought to be prevented from, 
and protected against, contracting marriages and having 
children. 

7. Diabetes. 

Diabetes mellitus is by no means a common disease among 
infants and children, but it is not so rare as some will have 
it, nor so frequent as those assert who have found sugar in the 
urine of infants whose food was supplied with an unusual 



138 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

quantity of sugar. Indeed, traces of sugar are often met 
with in the urine of nurslings. But this is not "dia- 
betes." 

In the ten years before 1860 there were thirty-one deaths 
from actual diabetes in Great Britain, in children under fifteen 
years, annually. Since that time the occurrence of the disease 
in every period of life appears to have increased considerably. 
Hereditary and family influences, such as neuropathies, epilepsy, 
insanity, syphilis, exert a great influence. Caron reports the cases 
of three children of the same mother, at the ages of three and 
a half and one and a half years, and of three months. Hydro- 
cephalus, injuries to the head, colds, atrophy of the pancreas, 
dysentery, measles, and scarlatina are referred to as causes. In 
the few cases which have come under my own observation I 
could not elicit a cause. The highest percentage of sugar I 
have noticed in a child (boy of four years) was six and one-half. 
Heubner observed eight and one-half, with a daily quantity of 
five thousand grammes, or three and a half quarts. The prog- 
nosis is not so good as Redon and a few others appear to believe. 
The disease runs a more rapid course in infants and children 
than in adults, and terminates more readily in coma and death. 
Therefore the treatment must be circumspect and energetic. 
Strict antidiabetic diet must be enforced. Fortunately, the 
young, with very rare exceptions, are apt to live on milk 
mostly. Thus less difficulties are encountered in them than in 
adults. For these also milk, skimmed or not, forms a princi- 
pal and beneficial part of their nutriment. The medicinal 
treatment of the young requires some modifications. The 
facility with which cerebral symptoms ("coma") are devel- 
oped, renders the persistent use of alkalies advisable (mineral 
waters), and forbids the use of opium. Iodoform, which I 
have seen to render fair service in adults, in daily doses of 
from ten to twenty grains internally, is seldom tolerated by 
the young, even in proportionately small doses. Arsenic 



CONSTITUTIONAL DISORDEKS. 139 

may be given in increasing doses a long time, the bromide as 
well as other preparations, one drop and more of Fowler's 
solution, largely diluted, after meals, three times daily, the 
dose to be increased gradually until doses of from two to four 
drops are taken. As in every disease which resists treatment 
to an unusual degree, a large number of other medicines 
have been recommended. As these remarks are not a library, 
but written for practical purposes only, I abstain from enu- 
merating drugs which I believe to be useless. There is one, 
however, which, in connection with everything destined to 
improve digestion and assimilation, appears to have a very 
favorable influence on the diabetic process. Salicylate of 
sodium, with an alkaline beverage (Selters, Vichy), has a 
decidedly favorable effect. A child of five years may take 
from five to eight grains, three times a day, and continue its use 
for many weeks, to advantage. 

Diabetes insipidus is a rare disease, but more common than 
diabetes mellitus. A large amount of urine of a low specific 
gravity (1000J to 1005) is secreted daily. The increased mictu- 
rition, great thirst, and emaciation are among the prominent 
symptoms. In some cases there appeared to be a hereditary 
influence. Syphilitic and other brain lesions, and injuries, have 
been found to explain its occurrence. In one case of mine it 
ceased after the removal of' a taenia mediocanellata, together 
with a copious and constant salivation, in a girl of five years. 
Inveterate masturbation and consecutive "neurasthenia" ap- 
peared to be the cause of the excessive flow of urine in several 
children of from four to eight years. It ceased gradually with 
the restoration of correct habits and better general health. Of 
the remedies which have been recommended, I mention vale- 
rian, valerianate of zinc, bromides, salicylate of sodium, and 
galvanization of the head. All of these proved unsatisfactory 
in my hands. But I have seen good results, and sometimes 
speedy improvement, from the administration of ergot and 



140 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

atropia. A child of five years may take daily, of the former 
half a drachm or more (extr. fluid, or the corresponding amount 
of extr. ergot., or ergotin), of the latter one-hundredth of a 
grain or less. More reliable than either has been strychnia, 
in three daily doses of one-hundredth of a grain each, or 
more. 



INFECTIOUS DISEASES. 141 

V. 

INFECTIOUS DISEASES. 

1. Intermittent Fever. 

In older children it has the same type as in adults. We 
have acute and chronic forms, the quotidian, tertian, and 
quartan types. There are the same results and anatomical 
lesions. There is the general ansemia, the splenic tumor, the 
hemorrhages, the amyloid degeneration. 

It is only in infants and very young children that the diag- 
nosis becomes difficult. In them the type is mostly quotidian. 
Besides, the attack may come at irregular times. Not infre- 
quently is it seen in connection with catarrhal diseases, which 
appear to create a susceptibility to the poison. The chills are 
not easily diagnosticated. The sweating is very frequently not 
profuse. The tumor of the spleen can be recognized only at a 
late period, but the fever is apt to be very high. Sometimes 
the attack is not recognized because of the first symptom being 
a convulsion. For all these reasons the diagnosis is very often 
not made. 

Quinine ought to be given, if the attacks come at regular 
intervals, in a single dose, two or three hours before the attack. 
If they occur at irregular periods, it is better to divide up the 
total amount of quinine in three or four doses, to be given 
through the day. In the first case a dose of five grains will 
suffice for a child of three years ; in the second case eight or 
ten grains will be required. 

It is not always easy to give quinine because of the taste. 
A solution ought not to be tried for the same reason. One 
part of the sulphate of quinine may be given with forty parts 
of elixir simplex, but in every case the dose must be mixed 
just before given. The neutral tannate of quinine is taste- 



142 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

less, and may be given in powder, but for one part of the 
sulphate two and a half of the neutral tannate must be ad- 
ministered. The sulphate may be given mixed in chocolate — 
older children will greedily take it — or in coffee or syrup of 
coffee. When it cannot be given internally, rectal injections 
may take the place of the internal administration. No acid 
must be added to the solution; therefore very soluble prepa- 
rations only must be used, for instance, the bromide, the 
muriate, the bisulphate, the carbamide; or suppositories can be 
given, but with less positive effect than that of other modes of 
administration. Inunction of quinine has been recommended 
a great many times. The ointments made as usual with ani- 
mal fats have but very little effect. Where it would be im- 
possible to use any other method, quinine might be dissolved 
and mixed with fat and a larger quantity of lanolin ; but even 
in this case the dose which really penetrates the skin and enters 
the circulation cannot be determined. A subcutaneous admin- 
istration of quinine becomes necessary when no other can be 
resorted to, or when an immediate effect is required. The 
best preparation for the purpose is the carbamide, which will 
dissolve in five or six parts of water, and give rise to less 
induration than we are liable to meet with when using the 
other salts. 

In the chronic form arsenic is the principal remedy, as in 
the cases of adults. A child of three years may commence 
with one drop of liquor potassii arsenitis (Fowler) three times 
a day, to be administered as detailed in a former essay. The 
liquor sodii arseniatis of the Pharmacopoeia may take its 
place in those cases in which the stomach is very irritable ; 
also the preparation of the same name as introduced by Pear- 
son, which is ten times milder than the officinal preparation, 
and must be given in proportionate doses. In a number of 
cases the solutions of arsenic are not well tolerated, and the 
arsenious acid may be given instead. It may be given in 



INFECTIOUS DISEASES. 143 

pills to older children in doses of a one-hundred-and-fiftieth 
to one-hundredth of a grain, three times a day, or more, 
to children of three years, or it may be administered as a 
powder in combination with other medicines. It may be 
safely mixed with bismuth, for the disagreeable odor ema- 
nating from persons taking bismuth, which has been attributed 
to arsenic contained in the bismuth, really belongs to a minute 
dose of tellurium inseparable from some specimens of bismuth 
in the market. All these preparations of arsenic may and 
must be given for many weeks or months. Constitutional 
symptoms belonging to an overdose I have seen more fre- 
quently when using Fowler's solution than any of the other 
preparations. 

Tincture of eucalyptus has been given in acute, and par- 
ticularly in chronic, cases. It renders good service now and 
then in doses of from ten to twenty-five drops, three or more 
times a day. 

As there are very obstinate cases in the adult, so there are 
in children. In them, too, the spleen may remain large and 
the attacks return indefinitely. These are the cases which try 
the endurance of the patient and the patience of the physician. 
In them I have seen excellent results from the use of ergot 
these thirty years. Ergot may be given as fluid extract, and 
then a child of three years may take from a scruple to a 
drachm every day for weeks in succession, or a corresponding 
quantity of the extract of ergot, — that is, from three to ten 
grains every day, either in mixtures or, for older children, in 
pills. I have noticed in a good many cases, in which the 
fluid extract was not tolerated at all, that the extract of ergot, 
when given in the latter shape, was easily tolerated. 

2. Typhoid Fever. 

Its danger may come from a great many sources. 

First. From the feeble original condition of the patient. Dia- 



144 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

betes and alcoholism are rare in infants and children, hereditary- 
syphilis not to the same extent. But general anaemia, either 
congenital or the result of previous diseases, such as intestinal 
disorders or chronic respiratory ailments, is frequent. Chronic 
bronchitis, emphysema, and previously contracted diseases of 
the heart impair the prognosis considerably. 

Second. The amount and intensity of the poison floating in 
the circulation and introduced into the tissues. 

Third. Abnormally high temperature. 

Fourth. Insufficient power or actual failure of the heart. 

Fifth. Consecutive conditions, such as diarrhoea, intestinal 
hemorrhages, local or general peritonitis, perforations, or ulcer- 
ative endocarditis. 

Sixth. Complications which, however, sometimes are to be 
counted among the consecutive conditions, such as meningitis 
and nephritis. 

Preventive treatment has led to very good results. Many- 
houses and towns which were the seats of endemic typhoid 
fever have been rendered immune by improving the sewerage 
and the condition of the neighborhood. For typhoid fever 
and dysentery can be traced positively to exhalations of privies, 
while with regard to other diseases we can only say that animal 
exhalations of the same character may create a predisposition by 
impairing the general health, but are not able to produce specific 
diseases independently of other influences. Where the drink- 
ing-water is suspected, it ought to be boiled. No raw milk 
should be given. The fasces of the patient must be disinfected, 
though there be no diarrhoea, by crude muriatic acid, carbolic 
acid, copperas, or corrosive sublimate. The sick must be iso- 
lated, and the practice still prevalent in many hospitals to 
locate typhoid patients in general wards must be abolished. 

Can typhoid fever be aborted? or, in other words, can incu- 
bation be interrupted ? An affirmative answer to this question 
has often been given, but it is difficult to prove the correctness 



INFECTIOUS DISEASES. 145 

of the diagnosis in an alleged case of typhoid fever lasting a few 
days only. Still, there can be no objection to believing that 
the proliferation of the poison floating in the blood may be inter- 
rupted by antifermentative treatment, and it is certainly either 
justifiable or advisable to try the effect of otherwise not injuri- 
ous antifermentatives, such, perhaps, as creolin or bichloride of 
mercury. As regards the early administration of a large dose 
of calomel, its effect is notoriously good, no matter whether 
it acts as a disinfectant directly on the poison, or whether it 
simply relieves the intestinal tract of the poison introduced 
and in progress of proliferation. A child of three years may 
take a dose of three or four grains ; a child of eight years one 
of seven or eight grains. While the purgative effect of the 
calomel can be obtained by simply introducing the powder into 
the mouth, there to be absorbed, it is better in this case to let 
it be swallowed. It can be safely given during all of the first 
week of the disease. When, as frequently, there is constipa- 
tion during the course of the disease, calomel is no less bene- 
ficial, but then it must be given in smaller doses, which may 
be repeated. Small doses of a quarter of a grain to a half- 
grain, repeated several times a day, will even have a good 
effect after diarrhoea has been present and been relieved. 

With regard to the general treatment of the typhoid fever 
of children, we are equally liable to injure either by overactivity 
or by neglect. The so-called expectant treatment has its great 
dangers in the hands of those who make it their invariable 
rule ; it is safe in the hands of those only who have learned 
to treat the sick rather than the sickness. The air in the sick- 
room must be cool, the windows open. Drafts, it is true, must 
be avoided, but screens around the bed will permit the open- 
ing of both windows and doors. The bed-sheets must be 
smooth ; four or eight safety-pins will fasten them to the corners 
and sides of the mattress. At an early period the whole sur- 
face ought to be washed with either water alone or with alco- 

10 



146 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

hol and water. The hair, when long, ought to be cut. The 
children must be allowed plenty of water. Those who are 
liable to have dry lips and tongue must be made to drink a 
small quantity of either water or dilute muriatic acid in 
water, ten minims to the tumblerful, in small quantities every 
ten or twenty minutes. Fissures around the lips or in the 
tongue ought to be washed with a saturated solution of boracic 
acid, or, when bleeding, should be painted once a day with a 
mild solution of nitrate of silver (not more than one per cent.) 
and afterwards painted with an ointment consisting of boracic 
acid and lanolin. 

Very much depends on the mode of feeding. No solid food 
must be given. Boiled milk, broths, farinaceous decoctions, 
strained. For older children, one or two soft-boiled eggs, 
either the whole of them or the white only; meat-juice. As 
a general thing, more albuminoids than carbohydrates ought 
to be given. The food must be so arranged as to be digested 
in the stomach, and not encumber the intestines. If neces- 
sary, a small quantity of pepsin and muriatic acid may 
be given with it. Peptones may be given, but they must 
not form anything like the exclusive diet. At a later period 
very small quantities of toasted bread may be added to the 
milk. 

The tendency to complications with bronchitis requires 
frequent changes in the position of the patients. They ought 
to be turned from their backs to their sides every few hours, 
and back after a while ; otherwise they ought not to be moved 
too much. Particular care ought to be taken not to raise them 
too often. Physical and mental rest is an absolute necessity. 
Defecation must take place in the recumbent posture. They 
must not be permitted to strain. 

The danger arising from high temperatures varies in dif- 
ferent patients. Their injurious influences depend, from a 
clinical point of view, on many causes, foremost among which 



INFECTIOUS DISEASES. 147 

are both individual susceptibility and the length of time dur- 
ing which the child is exposed to its internal heat. A high tem- 
perature lasting but a certain time, and alternating with either 
an intermission or a remission (as, for instance, in intermittent 
or relapsing fevers), may not prove dangerous at all, and not 
require any treatment. But the frequent repetition of elevated 
temperatures, or their long duration, demand interference. 
Therefore they ought to be taken at least four times a day, par- 
ticularly as typhoid fever is apt to yield two daily exacerba- 
tions and remissions. 

Continued high temperatures in the course of typhoid fever, 
or intense fever at the very beginning of the disease, require 
treatment. In them the frequency and quality of the pulse, 
and the functions of the nervous system, are seriously disturbed 
at an early time. Under the influence of a cold bath both tem- 
perature and heart-beats diminish, arterial pressure increases, 
and the intellect becomes clear. But it has a peculiarly great 
influence on the infant and child. In them the surface is rela- 
tively larger than in adults, and the cooling more rapid and 
intense. The circulation is easily disturbed, the surface tem- 
perature not readily restored afterwards. It may happen that 
the internal temperature rises while the external blood-vessels 
are contracted by cold, and the internal organs become en- 
gorged. In those cases a hot bath is more liable to restore 
radiation from the skin and reduce internal heat. In every 
case, where no immediate reaction takes place, — mainly about 
the extremities, — after the child has been taken from the bath, 
this must not be repeated, and the feet kept thoroughly warm. 
In such cases a warm bath is infinitely milder and more 
useful ; or where the temperature is high and threatening, a 
cold pack — as detailed in a former essay — around the trunk 
is preferable. At the same time the feet must be kept warm 
and a stimulant given. Cold applications to the heart are 
frequently sufficient to reduce temperature. In such cases as 



148 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

develop sopor at an early period, together with high tempera- 
tures, the pouring of tepid or cool water over the head, or 
head and shoulders, is very beneficial. The contraindications 
to the use of the bath are general debility, weakness of the 
heart, cold extremities, a cold surface, complicated with high 
internal temperature, and intestinal hemorrhage. 

The medicinal agents used to reduce temperatures in typhoid 
fever are salicylate of sodium, antipyrin, antifebrin, phenace- 
tin, and quinia. Kairin and thallin deserve no recommenda- 
tion, for the reason that, while their effect is no better, their 
efficacy is soon exhausted, and the drug has to be repeated 
after very short intervals. All of the medicines mentioned 
above must be given carefully. To avoid a possible debili- 
tating effect on the heart, a general or cardiac stimulant must 
be given at the same time. All of them may be given in 
small doses, frequently repeated, when the remission is not 
marked ; but as a rule an occasional larger dose is preferable. 
Antipyrin can be administered internally, through the rectum 
or subcutaneously. A child of three years may take from ten 
to twenty-five grains a day, in from two to four doses, two of 
which have often to be given in close proximity (the second 
after an hour or two hours). The dose of antifebrin is but 
one-third or one-quarter of that of the former. It is, because 
of its more difficult solubility, not available subcutaneously, 
and less so than antipyrin, in the rectum. Phenacetin may be 
given in doses of from two to five grains, twice or three times 
a day, to a child of the same age. The administration of 
quinia follows, as a rule, the method detailed above, but in 
typhoid fever it is liable to disorder the stomach and intes- 
tine and produce diarrhoea or tenesmus. Its time is the re- 
mission, its single dose from five to seven grains, once a day 
or every other day, and its best indication the persistence of 
the splenic enlargement in the course of the third week of the 
disease. The combination of quinia with one of the other 



INFECTIOUS DISEASES. 149 

antifebriles yields good results quite often when one of them 
does not appear to be sufficient, in the same way that the 
effect of a tepid bath combined with an antifebrile is, now and 
then, quite astonishing. 

The intestinal tract is the seat of many dangers. Tympani- 
tes and meteorismus depend on the paralytic condition resulting 
from enteritis only, or enteritis and peritonitis. The latter is 
either local, and corresponds with the local ulcerations, or 
general. Cold applications are serviceable. Enemata of ice- 
water will sometimes do good ; or of an aromatic infusion 
(chamomile, anise, fennel, catnip); sometimes of turpentine 
half a tablespoonful or a tablespoon ful mixed with the fluid 
(water, or soap and water). The introduction of a large 
catheter, with one or more additional eyes, may relieve the 
lowest part of the intestine. Puncture of the inflated intes- 
tine by means of a small syringe (" hypodermic") is not dan- 
gerous in such cases where it is not required. Where it would 
be of service, however, — that is, in the very worst forms of in- 
testinal paralysis, with intense and dangerous inflation, — it is 
injurious. For in these cases the elasticity of the intestinal 
wall is gone, and the small punctures in the intestinal wall re- 
main open. I have seen faeces entering the abdominal cavity 
through them, and fatal peritonitis, of my own making. 

Diarrhoea, when moderate, need not be interfered with in 
any period of the disease. It is probable that the initial dose 
of calomel prevents it in a great many cases. When it is 
copious, such remedies as pass through the whole length of the 
intestine will render good service either by their soothing or 
disinfectant effect. Subnitrate or subcarbonate of bismuth, 
from a scruple to a drachm daily, are valuable. Salicylate of 
bismuth does not always act kindly on the stomach. Naph- 
thalin, half a grain to a grain every two hours, when tolerated 
by the stomach, — in most cases it is, — improves the odor of the 
evacuations and diminishes their number. In many cases I 



150 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

have given it, for its disinfectant action, from the very begin- 
ning of the fever. Salol, in doses of from one to three grains 
every two hours, has a similar effect. Mild doses of opium 
may be added, from half a minim to a minim of the tincture, 
every two or four hours. Resorcin is better tolerated than 
either, but it does not pass the whole tract. Cold applications, 
covered with rubber cloth and (or) flannel ; they must be 
changed every twenty or thirty minutes. Or warm applica- 
tions may take their places when the little patients are quite 
feeble and anaemic. Among the astringents, when required, 
I prefer acetate of lead. Both tannin (gallic acid is milder) 
and alum are liable to annoy the stomach. 

Constipation is much more frequent in our cases of typhoid 
fever in both the young and old than in the descriptions of the 
books, both European and copied. When not too persistent 
it is not objectionable; for most children have not suffered 
from constipation before the disease began, and accumulation 
of faeces is not a very prominent feature in them. When 
there is peritonitis it must not be disturbed, at any rate. In 
no case must strong purgatives be given. Castor oil in small 
doses may become necessary; half a teaspoonful or a teaspoon- 
ful, every few hours, may then be given, or small and re- 
peated doses of calomel, from a quarter to one-half of a grain. 
Rectal injections, tepid, of water with, or mostly without, tur- 
pentine, will be all that is required in most cases. 

Perforations require the treatment best adapted to euthanasia, 
opium and stimulants ; (mostly) cool applications to the abdo- 
men, and hot ones to the feet. 

Hemorrhages are not so frequent, as in the typhoid fevers of 
adults, in those of the very young, because of the superficial 
character of the ulcerations. But in older children the intes- 
tinal lesions are apt to be as grave as in more advanced 
periods of life. No food must be given for some time, drink 
in small quantities only, but repeatedly. Applications of iced 



INFECTIOUS DISEASES. 151 

cloths, ice-bladder, or a lump of ice — to lose no time — to the 
right hypochondrium. They may be moderately heavy, for 
some pressure may have a local influence. Hot injections 
into the rectum have no styptic effect, iced ones may act 
through reflex. Internally, alum or lead, one-quarter or one- 
half grain or more, every hour or two hours, with opium and 
digitalis. Ergotin, or fluid extract of ergot, and other prepa- 
rations of the drug which were claimed to be innocuous, I 
have seen to give rise, frequently, to indurations or abscesses 
after their subcutaneous administration. Their effect is mostly 
questionable, for typhoid hemorrhages are liable to cease soon, 
after a single attack. I have seen gangrene over a large sur- 
face after their use, and pyaemia several times. In the case 
of a little girl, I had to incise about sixty metastases in the 
course of two months before she was saved from a pyaemia 
which resulted from a single hypodermic injection. The in- 
ternal administration of ergot may be tried when the condi- 
tion of the stomach permits it. Subcutaneous injections of 
sclerotinic acid (one to five) have been recommended. To coun- 
teract the imminent fatal termination I have been compelled 
to perform transmission of blood in the case of an adult ; she 
recovered, but died on the fiftieth day of a relapse. In- 
jections into the subcutaneous tissue, of blood or salt water, 
have been advised. They prove what a sick human being 
may, or has to, submit to and perhaps overcome. Quidquid 
delirant medici pleduntur segroti. 

The condition of the heart cannot but influence the course 
of the disease, its complications and consecutive disorders. It 
cannot but be enfeebled by a serious and protracted disease 
such as typhoid fever; still, to what extent this feebleness will 
be exhibited cannot be predicted. Besides, it depends to a 
great extent on causes not exactly connected with the infection 
itself. Among these accessory causes are original — congeni- 
tal — debility and chronic heart-diseases previously contracted. 



152 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

Besides, the infection itself with its accompanying fes 7 er is apt 
to give rise to an acute myocarditis, or to granular degeneration 
of the heart-muscle. Among the symptoms of debility of 
the heart, which may easily lead to complete heart-failure, are 
pallor of the skin and mucous membranes, purplish and cyano- 
tic hue, particularly of the lips, ears, and finger-ends, mottled 
appearance of the surface depending on venous stagnation in 
the small blood-vessels, cold extremities and nose, slow or, 
more commonly, frequent pulse, which, moreover, is arhythmic, 
and a heart-beat the sounds of which are either split or em- 
bryocardiac, — that is, exhibiting equal intervals between the 
first and second sounds. 

The brain symptoms belonging to heart-failure are those of 
anaemia. When beginning to treat them, we must not forget 
the possibility of an error in the diagnosis of the condition, 
which may be quite serious, because the signs of anaemia and 
hyperemia are the same in many respects. However, the gen- 
eral indications for the treatment of heart-failure may be laid 
down in a few rules, the first of which refers to prevention. 
As heart feebleness must be expected in every protracted disease, 
and failure feared in many, we ought to act, as a matter of pre- 
vention, exactly as the surgeon does in his operations. Before 
the times of antisepsis there were a great many operations 
which would not lead to sepsis or erysipelas. Indeed, these 
cases were the minority, perhaps a small one at that. But no 
surgeon would at present perform any operation, either serious 
or trifling, without antiseptic measures. If he neglected them, 
he would justly be held responsible for any mishap in the 
shape of erysipelas or pyaemia. Now, the certainty of car- 
diac debility and the danger of heart-failure are much more 
threatening in an infectious fever than those complications of 
convalescence after an operation. Therefore in no case of 
typhoid fever ought the heart to be left alone to fight its own 
battle unaided, with the chances of being overexerted (with 



INFECTIOUS DISEASES. 153 

possible hypertrophy from that cause), fatigued, or exhausted. 
The doses of the cardiac stimulants cannot be stated categoric- 
ally, but the principle must be established that it is a good rule 
to give moderate amounts of digitalis, strophanthus, convallaria, 
sparteine, caffeine, etc. The particulars have either been stated 
in former essays or must be left to the judgment of the prac- 
titioner. Digitalis and strophanthus may derange the stomach 
after a while ; digitalis may not act quickly enough under cer- 
tain circumstances ; in such a case sulphate of sparteine, which 
is readily dissolved, absorbed, and eliminated, in doses of one- 
tenth to one-quarter of a grain every two or four hours will 
render good services. Caffeine must not be given when there 
is hyperemia of the brain. The sodio-benzoate and sodio- 
salicylate of caffeine dissolve readily in two parts of water, and 
are reliable aids in sudden attacks of heart-failure, in hypo- 
dermic administration. Camphor internally, in doses and ac- 
cording to methods described before, will answer well in either 
the presence or absence of pulmonary complications. In cases 
of emergency its subcutaneous administration works admirably 
in either ether or almond oil, the former in ten- the latter in 
twenty-per-cent. solutions. The latter is less painful, and 
obstructs the instrument less readily. 

Carbonate of ammonium disorders the stomach more fre- 
quently than camphor is apt to do. Muriate of ammonium has 
no stimulant effect at all. Brandy and whiskey, when of good 
quality and well diluted (at least one in four or five parts of 
water or milk), hold the first rank. That they should, while 
sufficient doses must be insisted upon, not be given at all unless 
indicated, and omitted as soon as no longer wanted, is self- 
understood. Still, I know that they are often continued too 
long, and the occurrence of cirrhosis of the liver in children' 
who exhibited no other cause of the disease except the pro- 
tracted use of alcohol for alleged medical reasons, are by no 
means unheard of. Champagne will often take the place of 



154 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

brandy and whiskey when speedy stimulation is required, or 
Tokay, Madeira, Sherry, or a California wine, when the former 
are objected to because of their taste. When there is diarrhoea, 
opium given in small doses, perhaps half a minim of the tinct- 
ure every hour or every two hours, to a child of three years, 
will act both as a cardiac stimulant and astringent. Of Sibe- 
rian musk as a powerful stimulant I have spoken in a previous 
chapter. Nitro-glycerin in doses of a two-hundredth or one- 
hundredth of a grain, repeated frequently until four or six doses 
have been taken, will be found a vigorous remedy when, while 
the heart is still found acting, the arterial pulse is flagging. 

Whatever medicines may be found desirable, the child must 
be kept absolutely quiet. In a recumbent posture it has to 
remain, as a rule ; thus the food has to be given, thus it has to 
be carried to the window, or into the open air, if circumstances 
permit. Many a case will exhibit a wonderful improvement 
on the lawn, or under shade-trees, that looked like being near 
extinction within the four walls. 

Besides, the surface has to be kept warm. It is principally 
the extremities which require external heat. A hot bath, 
without or with an aromatic addition, and hot injections into 
the bowels will do a world of good in many a desperate case, 
always provided that the manipulations required are absolutely 
gentle and not exhausting. 

To relieve complications of the brain in typhoid fever 
the hair ought to be cut very short, the head kept cool, 
feather pillows not tolerated ; the head of small children 
may be washed frequently, or water poured over it while 
the body and throat are protected by an india-rubber cloth. 
The application of ice- water directly to the head in small 
children is not tolerated for a long time. It may give rise to 
collapse, and must be carefully watched. While the head is 
to be kept cool, the feet must be kept warm. Mustard foot- 
baths and hot applications to the feet, cold water or an ice- 



INFECTIOUS DISEASES. 155 

bladder to the heart, an ice-bladder around the neck, will be 
found very comfortable. When there is the slightest brain 
complication not depending on the infection itself or anaemia, 
no alcohol must be given, no opium, and no caffeine, though it 
may appear indicated by the condition of the heart. The head 
ought to be kept high, and it is sometimes necessary where the 
meningitic symptoms are quite clear to resort to local depletion. 
In these cases the leeches maybe applied to the mastoid process 
or, better still, to the septum narium. Where the brain symp- 
toms belong to the infection alone, or to anaemia, opium is 
well tolerated, and relieves sleeplessness and the general irrita- 
bility. Now and then codeine may take its place, or the hydrate 
of amylen or chloral hydrate. Sometimes the subcutaneous 
injection of morphine, one or two minims of Magendie's solu- 
tion, will give instantaneous relief. Warm bathing will prove 
beneficial in such conditions of general excitability. In these 
cases the use of cold must be carefully avoided. 

During convalescence sudden changes in feeding must be 
avoided. It is dangerous to give other than fluid diet before 
the tenth day after the fever has disappeared. After that time 
white meats, plain puddings, and jellies may be added. Raw 
fruit must not be given under any circumstances. Patients 
must not be taken out of bed sooner that a fortnight after their 
fever has disappeared. Older children must not be allowed to 
read. No visitors ought to be admitted during that time any 
more than during the duration of the disease, for during that 
very time weakness of the cerebral functions makes its ap- 
pearance or, when met with afterwards, is traceable to it. Dur- 
ing that time the temperature and the movements must still 
be watched very carefully, for relapses may set in at any time. 
Such relapses are very frequently the result of improper food, 
which will irritate the intestinal ulcerations, the process of 
whose healing is thereby interrupted. The greatest care must 
be taken in those cases in which the spleen, when tumefied 



156 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

during the progress of the disease, will not nearly assume its 
normal size about the end of the third week. When it remains 
large, a relapse may be looked for. 

The large number of consecutive diseases which may result 
from typhoid fever are ample proofs that all such measures are 
by no means superfluous ; multiple abscesses of the muscles, 
ostitis, epiphysitis, and arthritis are not very uncommon after 
typhoid fever. Noma is now and then seen, but it is only just 
to state that epiphysitis and arthritis are not so frequent after 
typhoid fever as, for instance, after scarlet fever, and noma 
not so frequent as after measles. But purpura may remain 
behind. Parotitis is not very uncommon. Thrombi in the 
extremities are sometimes met with. Erysipelas, laryngeal 
perichondritis, and cutaneous gangrene are by no means rare. 
But it is certain that many of these occurrences can be avoided 
if greater care be taken during the progress of the disease. 

3. Cholera. 

The form of acute gastro-enteritis which has been described 
under the head of "cholera morbus" when met with in the 
adult, and attracted intense attention a few years ago when 
Tinkler and Prior discovered their comma-bacillus, resembling 
in most points that of Asiatic cholera as found by Koch, is 
a frequent occurrence among infants and young children. 
They are attacked during the summer months or in hot 
rooms, where milk will be readily decomposed, and when 
artificial food of doubtful quality and improper composition 
is administered. Many of these cases must not be claimed 
as infectious, for their alleged epidemic character need not 
be anything but the occurrence of the same affection in the 
many who are exposed to the same unwholesome influences. 

Among the many microbes met with in the intestines of 
infants thus affected, no specific bacillus has been discovered. 
It is true that we meet, occasionally, with reports of cases 



INFECTIOUS DISEASES. 157 

of intestinal mycosis exhibiting bacilli, resembling those of 
anthrax, in the contents, epithelia, and submucous tissue of 
the intestinal tract, and also in the chyle-ducts and the lymph- 
bodies, but both the symptomatology and the pathological 
anatomy of the cases are exactly like those of the acute dys- 
pepsia, or uncomplicated acute gastro-intestinal catarrh of 
infancy and childhood. The treatment of all these different 
forms will, therefore, be discussed at a later occasion. 

The management of Asiatic cholera, when occurring at an 
early age, differs in no way from that required in the adult. 

4. Dysentery. 

The sufferings from dysentery are so intense, and the 
dangers from its acute or chronic state so threatening, that 
active measures must be taken at once. A brisk purgative 
ought to precede every other treatment. Castor oil in sufficient 
quantities, or calomel — according to age — in doses of from one 
to eight grains, will have a favorable effect, the latter acting 
both as a laxative and a disinfectant. The general rules of 
medicinal and hygienic treatment are those I laid down in my 
book on " The Intestinal Diseases of Infancy and Childhood" 
(G. S. Davis, Detroit, Michigan, 1887). It is these by which 
I shall be guided in most of the following remarks. 

The food must be liquid. Milk and strained farinaceous 
decoctions must be the exclusive diet for the first acute stage. 
It is on the general condition of the patient that the adminis- 
tration of other articles of food, such as jellies, beef- or mutton- 
broth, egg, or alcoholic and medicinal stimulants (either 
general or cardiac), will depend in the course of the disease. 

Great sensitiveness of the left hypogastric region and local 
heat will be alleviated by the application of ice. Very young 
infants, however, bear ice but a short time, whether applied to 
head or abdomen. I advise to watch the effect of the appli- 
cation either of the ice-bladder or the ice-cold cloth. Now 



158 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

and then, even in adults, we meet with an idiosyncratic incom- 
patibility with cold. That has to be taken into account. 
Indeed, quite often warm applications of either water or 
poultices prove more efficient in regard to the two indications, 
which consist in alleviating irritation and reducing tempera- 
ture. 

The subnitrate and the subcarbonate of bismuth do not 
only cover and protect the mucous membrane, but have also a 
decided antifermentative effect. Thus bismuth is surely in- 
dicated in irritated conditions of the mucous membrane; it 
seldom fails when given in sufficient doses. There is no harm 
in sometimes giving it in such doses that part of the introduced 
material will pass through the entire length of the intestinal 
tract without undergoing decomposition. As its taste is not 
disagreeable, it maybe given together with tannin and opium; 
the daily dose ought not to be less than one drachm or a drachm 
and a half (4.0 to 6.0). At the same time the passages ought 
to be examined as to their reaction. Abundant acid, so fre- 
quently found in the slightest intestinal anomalies, requires the 
additional administration of alkalies. In most cases carbonate 
of lime is preferable to either magnesium or the carbonate or 
bicarbonate of sodium, the salts of both of which are apt to 
increase diarrhoea. Sometimes, particularly when the stomach 
can be relied upon, the salicylate of sodium may be added to 
the internal treatment. Beside the favorable effect of the 
sodium in the intestinal tract, the salicylic acid may prove 
beneficial both by its antifebrile and disinfectant action. Salol, 
one or two grains, or resorcin, one-quarter or one-half of a grain, 
may take its place. The latter is better tolerated than the for- 
mer, but salol has a better chance to reach the lower part of the 
intestine. 

Opium and its alkaloids are invaluable in the treatment of 
intestinal ulcerations. The objections to their use are decidedly 
exaggerated. Such accidents as have been reported in the 



INFECTIOUS DISEASES. 159 

journals as resulting from the administration of opium must 
be attributed to the fact that the dose was either absolutely or 
relatively too large, compared with the idiosyncrasy of the 
patient. Dysentery both requires and tolerates larger doses of 
opium than an average diarrhoea, no matter whether the latter 
be the result of catarrh or ulceration of the small intestine or 
the caecum, or the upper part of the colon. In this respect 
dysentery stands abreast almost with peritonitis. The main 
indications are to relieve pain, reduce peristalsis, and diminish 
the copious serous secretion ; no other remedy fulfils all of 
them so well. For this purpose it ought to be given inter- 
nally; for enemata containing opium may act favorably, but 
the more intense the tenesmus and the greater the hyperemia 
or the more extensive the ulceration, the less reliance can be 
placed on its effect, and the amount of the opiate thus brought 
into real action cannot be estimated. Among all the opiates I 
prefer a tincture, or the wine, or opium in substance, or Dover's 
powder; but rarely have I injected morphia under the skin. 
The effect of the drug is easily watched and controlled, by 
commencing with moderate doses, not repeating them too 
often, and being guided by the effect obtained. If opium is 
to be discarded, opium with hyoscyamus, or with belladonna, 
or hyoscyamus or belladonna alone, may take its place tem- 
porarily. Severe tenesmus may require the painting of the 
protruding part with Magendie's solution. 

Astringents may either be given in combination with opium 
or separately. They are expected to pass wholly or partly 
through the entire length of the intestinal canal, thus coming 
into contact with the inflamed and ulcerous mucous membrane. 
Among those eligible are tannin, gallic acid, and vegetables con- 
taining the same (ratanhia, catechu), besides subacetate of lead, 
nitrate of silver, and pernitrate of iron. 

The daily dose of tannin, when it is to be taken for a long 
time in succession, is from ten to fifteen grains, subacetate of 



160 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

lead five to ten grains, nitrate of silver one-fourth to one-half 
grain. The latter ought not to be given more than a week, or 
two, in succession, for fear of argyria, two cases of which oc- 
curred in my own practice, and of my own .making, many 
years ago. All of these medicines are best taken, if possible, 
in the form of pills. They appear to be better tolerated, and 
are certainly more effective. 

The use of keratin, when it becomes handier and cheaper, 
will facilitate their efficiency to a considerable extent. 

Another antiseptic which I have frequently administered 
internally in every description of intestinal ulcerations, in both 
acute and chronic form, is naphthalin. For its doses, and the 
methods of its administration, and some account of its effect 
on intestinal ulceration in general, I refer to the chapter on 
typhoid fever. We have to expect a great deal from such 
topical medication, and it appears that it will be one of the 
great refuges in all infectious diseases whose principal locali- 
zation is in the intestine, as, for instance, Asiatic cholera. 
With creolin I have no personal experience as yet. 

Adults will take from fifteen to seventy-five grains daily, 
in powders, capsules, or mucilage. Children bear, as a rule, 
according to their ages, from one-half of a grain to two or 
three grains, every two or three hours, in some mucilaginous 
substance Some do not bear it well, but when such is the 
case, the stomach will give warning at once. 

The temperature will but rarely be so high as to require 
antipyretic medication. Frequent enemata will often reduce it 
effectively. Very young infants may demand an occasional 
dose of antipyrin or acetanilid (antifebrin) when the heat 
threatens either the nervous system or the normal structure of 
the tissues of the body. 

Consecutive paralysis requires a mild galvanic current in 
the beginning. The daily application both to the spinal cord 
and the extremities need not exceed ten minutes ; the electrodes 



INFECTIOUS DISEASES. 161 

must be large, and the current reversed after five minutes. 
After a few weeks the interrupted current may be added the 
same length of time, but it must be applied to the paralyzed- 
muscles only. Together with the latter, strychnia or (and)i 
phosphorus may be used, in daily doses of one-thirtieth of a 
grain in the case of a child of four or five years. 

The local treatment of chronic dysenteric ulcerations requires 
the use of enemata. Their indications vary. They are to 
evacuate the bowels, or to reduce the irritability of the dis- 
eased intestine, or to accomplish an actual cure. These indi- 
cations cannot be fulfilled separately; sometimes two, some- 
times all three, can be at the same time. The nature and 
quantity and the temperature of the liquid to be injected de- 
pend in part on the end aimed at, in part on the irritability of 
the individual intestine. Sometimes the bowel objects to the 
introduction of small amounts ; sometimes, however, large 
quantities are tolerated very easily indeed. To introduce 
small amounts, the selection of the syringe is a matter of 
indifference, provided the liquid enters the bowel gently and 
without pain. To inject large quantities, undue pressure and. 
local irritation must be avoided. Thus the fountain syringe 
alone will answer ; it ought to hang but a trifle above the level 
of the anus, say from six to twenty inches. The temperature 
of the liquid is not always a matter of great importance. Some 
recommend the injections to be ice-cold, some, however, tepid ; 
both are frequently recommended as panaceas. But the prac- 
titioner will soon ascertain that some bear and^require the one, 
some the other, some, indeed, very hot ones. 

In my experience, for the large majority of patients tepid 
injections answer best. Not rarely is the intestine in such 
a condition of irritation that even small quantities of a very 
cold fluid are expelled at once. And again, there are cases in 
which enormous amounts of either cold or warm water are 
readily received. To accomplish the purpose of evacuating 

11 



162 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

the bowel, plain water will often suffice, but three- fourths of 
one-per-cent. solutions of salt in water will usually prove more 
acceptable. Additions of bitartrate of potassa, or castor oil, 
have proved so uncomfortable in my cases that I have dis- 
carded them long ago. However, when the secretion of mucus 
on the rectal and intestinal mucous membranes was very large, 
one- or two-per-cent. solutions of bicarbonate of sodium an- 
swered very well indeed. For the purpose of clearing the 
intestines, either of faeces or the morbid products, a single 
enema is insufficient. It ought to be repeated several times 
daily. When much mucus is secreted and tenesmus intense, 
it may be applied after every evacuation. In many cases the 
substitution of flaxseed tea or mucilage of gum acacia will 
prove advantageous. I have had to continue them for weeks 
for both their evacuating and alleviating effect. When, how- 
ever, the latter alone is aimed at, — that is, when tenesmus is to 
be relieved, — small quantities will usually suffice. An ounce or 
two of thin mucilage, or starch-water, or flaxseed tea, with tinct- 
ure of opium, or better, extract of opium, prove very comforting. 
Glycerin in water has been recommended for the same purpose. 
The former alone, or but slightly diluted, irritates, nay, cauter- 
izes. It will require close judgment and individual experience 
to ascertain the degree of dilution, if it be used at all. 

When a local curative effect is aimed at, injections of small 
quantities are sometimes insufficient. As the local lesions are 
often extensive, the amount to be injected must be pretty large. 
Almost always astringents are required. Sulphate of zinc, or 
alumina, subacetate of lead, nitrate of silver, tannin, chlorate 
of potassium, ergotin, salicylic and carbolic acids, and creasote 
have been recommended. Of the more common astringents I 
prefer alumina or tannin in one-per-cent. solutions. Creasote 
answered well in solutions of one-half of one per cent. Salicylic 
acid resulted more frequently in pain than in benefit. Car- 
bolic acid, in solutions of one-half of one per cent., has proved 



INFECTIOUS DISEASES. 163 

very beneficial, but I have learned long ago to be very careful 
in regard to its administration because of its poisonous effects, 
particularly in very young patients. 

Injections of nitrate of silver may prove very useful in cases 
not quite acute. Before the solutions of a quarter of one per 
cent., or of one or two per cent, are injected, the intestine, 
ought to be washed out with warm water without salt. After 
the injection has been made it ought to be neutralized with a 
solution of chloride of sodium ; it is still better to wash the 
anus and the portion of the rectum within easy reach with that 
solution before the medicinal injection be made. For even 
the mildest solutions, when acting on the sore sphincters, are 
liable to give rise to intense tenesmus when no such care has 
been taken. 

When the ulcerations are but few, or in the lower portion 
of the bowels only, small quantities suffice. But extensive 
lesions require large injections, the patient being on his side, 
or in the knee-elbow position. In these cases the nozzle of 
the fountain syringe must be lengthened by attaching to it an 
elastic catheter, which is introduced as high up as possible, 
after the same plan that nutrient enemata are to be given. In 
a number of cases, both mild and severe, where neither the 
usual astringents nor nitrate of silver appeared to answer, I 
have been very successful these twenty years, when resorting 
to injections of subnitrate of bismuth. The drug is mixed 
with six or ten times its amount of water ; of this mixture 
from one to three ounces (30.0 to 100.0) are injected into the 
bowel, which has been washed out previously, twice or three 
times daily. The success was satisfactory, though a large 
portion of the injected mixture was soon expelled. 

Suppositories containing the above substances may prove 
beneficial. But in order not to irritate they must be so soft as 
to melt readily. They may always contain some opium. But 
its admixture is not always sufficient to relieve the irritability 



164 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

of the rectum. Indeed, to accomplish this end opium must at 
least begin to liquefy and to be absorbed, and absorption can- 
not be relied upon except where a part, at least, of the mucous 
surface is in a fair state of integrity. When no suppository 
can be tolerated, and the administration of an opiate to the 
intestine is indicated, the painting with Magendie's solution, 
or the injection of a small quantity of olive oil with tincture 
of opium, may still be tried. The local application of cocaine 
relieves pain, but the drug is readily absorbed, and great 
caution must be used in its administration because of its 
poisonous effects. 

5. Scarlatina. 

Preventive measures of the strictest nature are indicated in 
regard to no disease more than in the case of scarlatina. Its 
mortality is very great, in some epidemics even excessive ; and 
when the child survives, there may be a large number of 
sequelae which either terminate fatally, or in persistent injury 
to health, and in the curtailing of the enjoyment or usefulness 
of life. Among these are cardiac diseases, glandular affections, 
suppurative otitis, and nephritis. The first attack of the latter 
is not limited to the second or third week, when, it is true, it 
is mostly met with ; for I have seen it to appear on the 
thirty-seventh day of the disease, and Baumler reports the 
case of a child with hemorrhagic nephritis which started as 
late as the forty-fourth day. 

There is another momentous indication for strict prevention. 
The facility of being attacked is by no means so great as, for 
instance, in measles. It is but rarely that any of the young 
inmates of a house escapes contagion when measles has attacked 
one of them. The virus of scarlatina, however, is less catch- 
ing. Infants of less than a year suffer but rarely, though very 
severely when taken. The vast majority of those affected 
are less than five years old. After that period susceptibility 



INFECTIOUS DISEASES. 165 

becomes less from year to year, so that, indeed, a child who 
has been protected against scarlatina during its first half-dozen 
year attains a certain degree of immunity for the future. 

There is no reason to believe in a primary origin of scarla- 
tina. The efficacy of the virus is so persistent, and it clings 
so long to clothing, bedding, and furniture, that it can be 
carried and transmitted to long distances by persons, towels, 
toys, letters, and even domestic animals and articles of food. 
It is transferable through the whole duration of the disease, 
from the incubation to the disappearance of the very last 
symptoms. The incubation of scarlatina may last but a few 
hours, like that of diphtheria and erysipelas, or as long as nine 
days ; in this it differs greatly from measles, variola, and vari- 
cella. The last symptoms may not disappear until long after 
the fortieth day, which, it is true, is the average termination. 
The fine desquamation of the second week may have terminated 
entirely, but the gross peeling, particularly of the hands and 
feet, extends frequently to the end of the seventh or eighth 
week. It carries contagion as well as the desquamation of the 
former weeks, or as the breath of the patient, or his expecto- 
ration in the earlier periods. So slow is sometimes the process 
of elimination that Spottiswood Cameron claims that the end 
of the disease is seldom reached before the eighth week, and 
not always in the thirteenth. Whether the urine or the alvine 
dejections of the patient can spread the disease is not quite 
certain ; but as long as there is an uncertainty they ought to 
be treated as dangerous elements, and disinfected and removed. 

Sore surfaces appear to admit the poison. Scarlatina will 
enter through the integuments denuded by eczema. I believe 
I have lost two patients because I operated upon them during 
the prevalence of an epidemic of scarlatina. A child of four 
years, on whom I resected the head of a femur, was taken with 
the eruption on the fourth day and died. Another one was 
stricken down thirty-six hours after the resection of a tonsil. 



166 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

In both cases I had reason to believe that I opened an inroad 
to the invading poison. 

Dispensaries and schools are the hot-beds of scarlatina. A 
single case waiting in the anteroom of a public charity until it 
be seen and diagnosticated may destroy a dozen innocents while 
craving the blessings of public beneficence. Schools ought to 
be closed during an epidemic. No child coming from a house 
with scarlatina must be admitted. Such as have been removed 
from the dangerous neighborhood and not exposed since may, 
after thorough disinfection of the clothing worn during the 
time of exposure, be allowed to return after an interval of ten 
days. 

The inunction of the patient with pork, vaseline, and simi- 
lar substances adds to the safety of the attendants by pre- 
venting the carrying into the air of the eliminated particles of 
epidermis. The soaping and bathing contributes to the same 
end, but is no reliable safeguard because the virus penetrates 
the whole skin down to the rete Malpighii. 

The sick and their attendants must be strictly isolated; 
during the winter, when the warm air rises and carries con- 
tagion with it to the upper part of the house, in the highest 
story. Whoever enters the sick-room — friend, nurse, or 
physician — ought to wear special clothing while inside, or at 
least a linen or india-rubber cover. The physician must dis- 
infect his hands after leaving his patient. In the room the air 
ought to be changed often. Draught can be avoided by means 
of screens. No dry linen or clothing must leave the room. 
It must be soaked in water, or better still, in a disinfectant 
fluid, before it is carried off, and boiled in soap and water im- 
mediately after arriving in the laundry. The same rules which 
hold good in the cases of infectious and contagious diseases in 
general, those which refer to the disinfection of the room and 
furniture, and public vehicles which may have been used, 
must be obeyed to the letter. No room, in fair weather, will 



INFECTIOUS DISEASES. 167 

afford the same safety as a tent would, and in no disease, with 
the exception of variola and diphtheria, is the erection of 
special hospitals more needed than in scarlatina. 

The medicinal treatment of mild cases may be expectant. 
Cooling drinks — ten or twelve drops of dilute muriatic acid in 
a goblet of water — will often suffice. The food must be liquid, 
or at most semi-solid ; in the first week milk and farinacea. 
Constipation in the first period is aptly relieved by a dose of 
calomel or a vegetable aperient. Diarrhoea, particularly in 
the later stages, requires bismuth, opium, perhaps astringents, 
such as lead, and at all events antifermentatives, such as 
resorcin, salol, or naphthalin ; the mild form of stomatitis 
and pharyngitis, half a grain or a grain of chlorate of potas- 
sium in a teaspoonful of water every hour or two hours. The 
frequent complication with diphtheria must be met by the 
appropriate treatment of the latter; it will be the subject of 
special remarks at a future time. Diphtheria setting in on the 
fourth or fifth day is but seldom alarming ; when on the first 
day, or previous to the scarlatinous eruption, it is quite 
ominous. In this case it is often accompanied with rapid 
glandular swelling and serious symptoms of sepsis. Applica- 
tions of ice to the swollen neck will often keep the tumefaction 
within certain limits. When gangrenous degeneration of the 
glands cannot be prevented, and local suppuration occurs in 
the centre, deep incisions and the local use of carbolic acid are 
required in the same manner in which the same affection is 
dealt with in diphtheria. In milder cases, two applications 
daily of one part of iodoform in eight or twelve of collodion 
have a good effect. 

High temperatures do not require very active treatment 
unless they result in functional or organic changes of the heart 
or brain. As long as these two organs perform their duties 
normally the temperatures may be left alone. A very frequent 
and feeble pulse with a high temperature requires, beside a 



168 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

cardiac tonic, quinia (with the restrictions mentioned in No. 
2), washing with cool water, or water and alcohol, cold appli- 
cations to the heart, or a warm bath. Antifebrin and anti- 
pyrin are not to be recommended in these conditions. Delirium 
and somnolence, also convulsions, may be the result of high 
temperatures, and, particularly when the whole body, feet 
included, is hot, require the same treatment. Antipyrin, how- 
ever, I have never seen to reduce the temperature in con- 
gestive or inflammatory conditions of the brain. The latter 
may be the direct result of the infection, but also at a somewhat 
later period of rheumatism. In either case the treatment does 
not materially differ from what it would be under ordinary 
circumstances. The latter form requires salicylates, both the 
application of ice to the head, counter-irritants to the feet 
(sinapisms) and intestines (calomel), and in most cases leeches 
to the septum narium or mastoid processes. The vital indica- 
tion proceeding from the condition of the brain is here of the 
greatest importance. 

When the same symptoms set in with or without a high 
rectal temperature and cold extremities, a mottled skin, and a 
cyanotic hue, the large amount of the virus which has invaded 
the system demands strong stimulants, — ammonia, musk, and 
camphor. They act better than alcohol. To their internal 
administration may be added camphor dissolved in almond 
oil, sulphate of spartein in water, subcutaneously, in free and 
frequent doses. These symptoms of poisoning while the tem- 
perature is but low bear opiates (morphia, one-fiftieth or one- 
twentieth of a grain, in repeated doses) quite well. Universal 
heat requires tepid bathing, with cold affusions over, or appli- 
cations to, the head ; a cool surface, with cold extremities and 
frequent and filiform pulse, hot bathing and powerful friction, 
and hot enemata, with stimulants. 

Vomiting before and with the eruption is a frequent symp- 
tom. When moderate, it may be left alone ; no food must be 



INFECTIOUS DISEASES. 169 

given for a number of hours, ice-water in teaspoon doses, or 
an ice pill, every five or fifteen minutes. When quite severe 
and exhausting, small doses of an opiate, once every hour or 
two, will be found useful. In a few obstinate cases the 
muriate of cocaine in doses of oue-twentieth or one-fifteenth 
of a grain answered well ; in others, arsenious acid, every two 
hours, a two- or three-hundredth part of a grain. 

One of the early complications is rheumatism. It makes its 
appearance often on the third or fifth day. In some cases it 
is muscular, and then mostly confined to the lower extremities. 
In others articular, but with less swelling than we are inclined 
to expect. Indeed, articular rheumatism in general exhibits 
the usual symptoms to a less characteristic degree than in 
adults, but they are so pronounced as not to be mistaken. 
This rheumatism ought to be treated at once, for endocarditis 
complicates it in infancy and childhood very much more 
readily than in advanced age. Most of the cases of scarlatinal 
endocarditis carried into later life are due to rheumatism. The 
joints ought to be well covered with soft cotton, and salicylate 
of sodium given every two or three hours in doses of from four 
to ten grains. 

Endocarditis and pericarditis, without rheumatism, are but 
rare occurrences. Ulcerous endocarditis I have not seen except 
with serious general sepsis, caries of bones, thrombosis of a 
sinus, and other symptoms of general pyaemia. 

Suppurative inflammations of joints are very rare. They 
form part of generalized pyemia. There is an affection of the 
epiphyses, however, which is very common and differs from 
the above. It consists in extensive hyperemia, and possibly 
inflammation. Clinical observation yields quite a number of 
cases of infectious diseases, but mainly scarlatina, in which 
during convalescence, and long afterwards, the regions of the 
joints are swollen and painful. This epiphysitis is the cause 
of the rapid increase in the growth of children who have passed 



170 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

through scarlatina, but may also be the cause of serious changes, 
from simple " growing pains" to suppurative separations of the 
epiphysis from the diaphysis. In every such case, during 
convalescence and afterwards, the joint ought to be well sup- 
ported by soft splints, emplastr. hydrarg., iodoform collodion, 
absolute rest enjoined, and phosphorus given in three daily 
doses of a two-hundredth of a grain, or more. 

The complications with pneumonia and pleuritis are quite 
frequent; the latter is apt to be purulent; if so, its existence 
explains in many cases the continuance of the high tempera- 
ture. In every case, purulent or not, the indications are 
opposed to an expectant plan of treatment. Both general and 
cardiac stimulants and tonics are required. 

Hemorrhages are not frequent, but ominous when they 
occur. As a rule, they are the result of embolic processes, 
and complicated with local gangrene. Spontaneous throm- 
boses, however, of the extremities, or the cheeks (" noma"), are 
not so frequent in scarlatina as they are in measles. 

The presence of pemphigus during the eruption appears to 
indicate a high degree of vaso-motor paralysis. It is an ominous 
complication and requires stimulants as above. Urticaria is 
more troublesome than dangerous. The inunction with pork, 
vaseline, or glycerin — soothing and pleasing in most cases of 
scarlatina — may suffice to relieve it. Now and then mild 
alkaline lotions (bicarbonate of sodium in water, 1 to 100), or 
the washing with carbonated alkaline waters (from the siphon), 
or with a proper dilution of carbolic acid (1 to 200), will prove 
beneficent. When the burning and itching is quite annoying, 
naphthol five parts, and vaseline one hundred or one hundred 
and fifty, may be tried to advantage. 

The rules for the general treatment of scarlatina must 
necessarily be very much like those applicable to all infectious 
diseases. Thus in regard to them, and particularly to the 
debility and failure of the heart, I refer to my remarks on the 



*. 



INFECTIOUS DISEASES. 171 

treatment of patients suffering from typhoid fever. In scar- 
latina, and eruptive fevers generally, there is, however, an ad- 
ditional indication resulting from the participation of the skin 
in the process. Indeed, more than in other diseases, the hygiene 
of the surface has to be attended to. During the course of the 
disease, particularly during desquamation, a tepid bath, with 
soap, ought to be given from time to time, and the tempera- 
ture of the room and bed kept at equal heights. While the 
former is to be cool, the body must be well covered and kept 
warm. This is the more necessary, as nephritis may set in at 
any time during many weeks. This serious complication, it is 
true, may occur though the patient be kept in bed, in conse- 
quence of voluminous elimination of epithelia, and also perhaps 
of bacteric invasion, but exposure and sudden changes of tem- 
perature will always hold their place in etiology, in the minds 
of those who do not forget to notice the living clinical case 
beside the dead microscopical excrement. 

In this connection, while I reserve the subject of nephritis 
for some future occasion, I will only urge the advisability of 
beginning the treatment of scarlatinal nephritis with a moder- 
ate dose (one-half to one grain) of calomel, repeated from time 
to time, through the first two or three days. Its purgative 
effect, if too great, may be stopped by a small dose of opium 
given after every loose movement. 

6. Measles. 

The virus of measles appears to be more volatile than that 
of any of the other contagious diseases. The communicability 
appears to be greatest during the prodromal stage, and the in- 
vasion takes place, in all probability, through the bronchial 
mucous membrane. The incubation may last thirteen days, 
the nrst four or five of which may be attended with some fever. 
During all this time, and during its whole course, the disease is 
contagious. 



172 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

Very few cases are seen during the first six months of life. 
After that it is common, and repeated invasions are frequent. 
In many seasons the mortality is very trifling ; in some epi- 
demics it has reached thirty-three per cent, of all the cases. 
The first epidemic occurring in regions where measles had not 
been known previously was found to be very dangerous, and 
those which occur after long interruptions are likely to prove 
very severe. Thus the question whether the well should be 
separated from the sick will depend a great deal on the 
severity of the epidemic. 

The temperature of the room should be comfortable, a little 
warmer than in scarlatina, and the air moist. The light 
ought to be excluded to a certain extent, but not to absolute 
darkness. For a number of days the child should be kept in 
bed, unless very restless, in which case it may be taken out well 
covered. It is a good rule to keep the patient in bed a week 
after the disappearance of the fever, and in the house ten days 
or a fortnight longer. Relapses are not uncommon, and those 
particularly who have hereditary tendency to tuberculosis ought 
to be protected from exposure. Especial care must be taken 
during the cool or rainy season. 

Mild cases require mostly a hygienic treatment only; still, 
every case has its own indications. Where there is otitis, 
bronchitis, pneumonia, or dysentery, it is self-understood that 
the patient must be kept in bed during the continuance of the 
complication. Warm and dry weather and a sandy soil will 
permit a patient to leave the house sooner than under other 
circumstances. 

Constipation may demand gentle treatment in the beginning. 
As a rule, an enema will suffice. Castor oil or the elixir of 
rhamnus purshiana may sometimes be required. No drastic 
should be used because of the tendency to diarrhoea or dysen- 
tery prevailing in many instances. For the same reason no 
glycerin should be injected into the rectum. 



INFECTIOUS DISEASES. 173 

A convulsion in the beginning of the disease does not 
always mean great harm. It takes the place of the chill in 
the adult, but is more dangerous because of the possibility of 
hemorrhages occurring while it lasts. Thus it ought to be 
cut short as soon as possible. Chloroform inhalations will 
relieve the spasm, chloral hydrate internally, or in an enema, 
the persistent irritability. Warm bathing may be resorted to 
when under these circumstances the eruption is slow in show- 
ing itself. The head has to be kept cool, the feet warm. 

Epistaxis may be left alone while mild. It is sometimes a 
relief to the congested mucous membrane of the nares. When 
severe it has to be stopped. 

The organs of circulation do not suffer often in measles. 
Endocarditis is met with but very rarely, but in epidemics of 
unusual severity heart-failure is of frequent occurrence. It 
is to be treated according to the principles laid down in the 
articles on scarlatina and typhoid fever. A peculiar feature 
in very severe measles is the frequency of thromboses. In- 
deed, in no other infectious disease are they met with as often 
as in measles. The thrombi occur in the vulva, in the skin 
and subcutaneous tissue, about the face as cancrum oris (noma), 
on the distal parts of the extremities, particularly the legs. 
Purpura is not frequent, but gangrene of the skin is not at 
all uncommon in such cases. The odor in them, and in can- 
crum oris, is very offensive indeed, and requires strong disin- 
fectants and deodorizers. Thymol in solution of one to one 
thousand, iodoform in powder or in vaseline ointment, will be 
found serviceable. 

What has been called hemorrhagic measles is not always 
very malignant. In a great many cases it means nothing but 
the effusion of some hsematin into the eruption. 

As is well known, the respiratory organs suffer mostly in 
measles. There is always catarrh of the nose, which may 
lead at an early period to tumefaction of the lymph bodies 



174 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

around the neck. If such be the case the catarrh must not 
be left alone, but treated with gentle injections of a solution 
of salt water or boracic acid. The conjunctivitis connected 
with it requires tepid or cool application, or instillation several 
times a day of a few drops of a two-per-cent. cocaine solution. 
A moderate amount of bronchial catarrh may be left alone 
provided the cough is not very severe, for severe attacks of 
coughing, even without much congestion or inflammation, 
may produce bronchiectasis or emphysema. Particularly is 
such the case when there is complication with pertussis. 
Here morphine may be given in sufficient doses. Bronchitis 
is rarely dangerous unless it be capillary. Broncho-pneu- 
monia is always a serious complication and a very frequent 
one. In a number of cases its course is very rapid, accom- 
panied with cyanosis and a very small pulse. Active treatment 
is required in these cases. The inhalation of oxygen will 
now and then bridge over urgent conditions. Warm bathing 
and cold affusion in a warm bath will be of good service, 
for it is necessary that the patients, particularly small chil- 
dren, should cry. Unless they cry they will suffocate. Stimu- 
lant expectorants are in order, such as camphor, benzoic acid, 
or carbonate of ammonia. The muriate of ammonia is not 
sufficient. Cardiac stimulants are required at the same time, 
such as digitalis, spartein, musk. No depressant expectorants 
should be given. Antimonials should be avoided at any rate. 
There is always some catarrh of the larynx. When the 
croupous symptoms are very urgent the air of the room ought 
to be filled with steam, and the patient encouraged to drink 
as much as possible, particularly of alkaline waters. The 
internal administration of the iodide of potassium in moderate 
doses will do good service. So will an opiate, particularly at 
bedtime. In connection with the catarrhal affection of the nose, 
otitis is now and then seen. According to Schwartze, three per 
cent, of all the cases of otitis can be traced back to measles. 



INFECTIOUS DISEASES. 175 

During all this time the kidneys ought to be watched. It 
is true that nephritis is by no means a frequent occurrence 
in measles, but it has been found often enough to justify the 
greatest attention. 

Cerebral complications have no special indications. Rules 
for their treatment will form the subject of a future chapter. 

7. Rbtheln (Rubella). 
It has not yet conquered an indisputable place in pathology. 
There are still many who do not take it to be a separate dis- 
ease. The eruption looks mostly like measles, sometimes like 
erythema, or urticaria, or scarlatina. Many cases have been 
described which were connected with catarrh of the respiratory 
organs and of the throat, with glandular swellings and fever. 
These are the cases which have been described under the name of 
rubella morbillosa, and would be diagnosticated by many, my- 
self included, not as rotheln, or rubella, but as a mild form of 
measles. If there be any such special disease, no special treat- 
ment is required. 

8. Mumps. 

The incubation lasts a fortnight, and sometimes three weeks. 
Thus prevention by isolation can seldom be accomplished. 
The infection must be presumed to take place through the 
Stenonian duct. Thus a careful hygiene of the mouth must 
be considered the best preventive. Often the patients do not 
feel very sick. Many do not take to their beds. In many cases 
covering the swelling with cotton is sufficient to protect it. 
Where there is a great deal of pain narcotic applications may be 
made, or ice applied. The latter certainly reduces the amount 
of swelling, although it may not shorten the course of the 
disease. I have often found the application of iodoform col- 
lodion (one to eight or ten), made twice a day over the whole 
surface, quite successful. When there is a tendency to sup- 
puration, warm applications will favor it. Then incisions must 



176 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

be made in time, be large, and treated antiseptically. The diet 
must be that of all fevers, — fluid. A consecutive anaemia 
which is more frequent than the apparent mildness of the 
affection would seem to explain, requires generous feeding, 
iron, nux, and a change of climate. 

9. Variola. 

Vaccination ought to take place early, for variola in the 
first year is quite frequent among those not vaccinated. 
There are also many cases of variola among those not vacci- 
nated between the eleventh and twelfth years. The smallpox 
reports of the German empire emphasize the fact that no case 
of variola occurring in vaccinated children who had more than 
two cicatrices, terminated fatally ; nor was there a fatal case 
among those who were re vaccinated. There was no fatal case 
where the vaccination marks were very distinct, between the 
thirteenth and forty-fourth years. The fact that none died 
that exhibited more than two marks appears to prove that the 
single mark customary among us may not be sufficient. At 
all events, many of our children vaccinated in the first year 
of life will undergo a successful revaccination when they are 
only from four to six years old. At that time revaccination 
ought to be tried. 

Isolation is now recognized as an absolute necessity in the 
case of variola more than in any other disease. Thus little 
difficulty is encountered by ill will or ignorance. Patients 
with variola ought to be kept cool, washed frequently with 
cold or tepid water ; now and then an ether spray over sore 
parts will be found quite agreeable. Fever is sometimes very 
high, and ought then to be modified by antipyretics. The 
-delirium is sometimes so violent, and bordering on mania, that 
the inhalation of chloroform or the administration of chloral 
hydrate is required. The eyes ought to be covered with cold 
compresses, sore places covered with vaseline or lead ointment. 



INFECTIOUS DISEASES. 177 

Superficial sores particularly, and those which yield an offen- 
sive odor, should be treated with thymol, salicylic acid, or 
iodoform. Scabs must be removed from the nostrils so as 
to facilitate respiration ; abscesses should be opened in time 
and disinfected, and complications treated. One of the most 
severe complications is oedema of the larynx, or laryngitis, 
which may require, on short notice, tracheotomy or intubation. 
After the disappearance of the fever stage the patient ought 
to be bathed once every day or every other day, and inunc- 
tions of fat made all over the surface until desquamation is 
complete. 

10. Varicella (Chicken-pox). 

Bad cases must be kept in bed. Very few require medici- 
nal treatment. A small number of instances of consecutive 
nephritis are now on record ; thus the urine ought to be exam- 
ined in every case. 

11. Erysipelas. 

It is so communicable that even a physician may carry it. 
Still, it is not probable that the healthy surface can be attacked 
by it. As in most cases of diphtheria, so in all cases of ery- 
sipelas, a sore surface forms the resting-place of the disease. 
Erysipelas may make its appearance on an eczematous skin. 
On the head it sometimes escapes notice for some days. Ex- 
coriations of the anus and sexual organs, or slight injuries 
done by a pin or by the finger-nail, are sufficient to give rise 
to it. It often originates in the intertrigo of the infant, or in 
the neighborhood of a vaccination mark. In the latter case it 
seldom appears immediately after vaccination, very often not 
before the second week or later. Chronic nasal catarrh is a 
frequent cause. Some children will have erysipelas extending 
over both cheeks once or more every year. Slight or large 
operation wounds are a frequent cause ; so is diphtheria, and 
many cases are seen to take their start from a tracheotomy 

12 



178 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

wound. In the newly-born it appears, as a rule, on or near the 
navel, and is generally connected with universal sepsis. Pre- 
vention of the disease will mainly depend on the removal, or 
relief, of the several causes which have been enumerated. 

Every case of erysipelas must be isolated ; the diet and 
general treatment be regulated on general principles. The 
local treatment may be quite simple in some cases. The ery- 
sipelatous surface may simply be covered with soft cotton, or 
a powder of talcum, or of amylum, or one part of salicylic 
acid with perhaps ten parts of oxide of zinc and twenty-five 
of amylum. Applications of lead wash and opium, or of 
sulphate of zinc, have been in general use for a long time ; 
also of solutions of sulphate of iron; now and then the ap- 
plication or inunction of blue ointment. The latter I cannot 
advise because of the pain and irritation resulting. The in- 
flamed surface has been covered with collodion. Infants and 
children will not bear it. Ferreire has used, in a case of ery- 
sipelas on the leg of a child of two years and a half, a mixture 
of one part of resorcin in seven thousand five hundred of trau- 
maticin (0.008 : 60.0). Cold applications have been made, ice 
has been applied, and where the extent of the erysipelas is but 
limited, to great advantage. Incisions outside the inflamed 
portion have been advised. They are useless and brutal, be- 
cause the lymphatics are, as a rule, infected a good while 
before the inflammation shows on the surface. That is the 
reason why neither saturated solution of nitrate of silver nor 
the solid caustic have been of advantage. 

Hueter recommended many years ago the subcutaneous in- 
jection of a two-per-cent. solution of carbolic acid round the 
inflamed surface, and claimed to have confined every case 
within its original limits. In place of that, I advised many 
years ago the application, not on, but around, the erysipela- 
tous area, of a mixture of one part of carbolic acid in eight, 
ten, or fifteen parts of oleic acid. I have treated many cases in 



INFECTIOUS DISEASES. 179 

that way, and most of them quite successfully. The application 
was to be rubbed into the surface around the diseased part at 
frequent intervals, or, when the erysipelas was confined to the 
extremity, a band or compress soaked in the mixture was ap- 
plied above or below the diseased part, not infrequently with 
the result of stopping the process. Instead of the carbolic acid 
as administered by Hueter, Ducrey uses a solution of one part 
of corrosive sublimate in one thousand of water, and repeats the 
injections, which are to be made three centimetres apart, after 
twelve hours. A better plan, however, is, after all, to apply 
carbolic acid, one part dissolved in ten or fifteen of alcohol, di- 
rectly to and beyond the surface, every hour or every few hours. 
It is readily absorbed, and may do good. It will do good in 
most cases, but may do harm by affecting the kidneys. Thus in 
every case where it is to be applied the kidneys must be watched 
carefully, and particularly in young children. Carbolic acid 
being rapidly absorbed, will affect infants very severely. 

The internal administration of the tincture of chloride of 
iron has been considered a specific by many. That opinion is 
certainly based on an exaggeration of its merits. The prep- 
aration is, however, an antifermentative, and while being a 
vascular stimulant, does not give rise to fever in infectious 
diseases as it would do in simple inflammatory fevers. 

Abscesses complicating erysipelas require large incisions and 
antiseptic treatment. Erysipelas of the neck is very often 
complicated with oedema of the larynx, and may require scari- 
fication, tracheotomy, or intubation. 

12. Diphtheria.* 

The treatment must be mainly preventive. Every case of 
diphtheria must be isolated, during the winter on the upper 

* The therapeutics of diphtheria has "been the subject of a paper read by 
the author, by invitation, before the Philadelphia County Medical Society, 
on May 23, 1888, and part of the discussion in the Children's Section of the 



180 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

floor of the house, windows open as much as possible, furniture 
of any kind reduced to the least possible quantity, the room 
changed every few days, the bedding frequently. 

To what extent the infecting substance may cling to sur- 
roundings is best shown by the cases of diphtheria springing 
up in premises which had not seen diphtheria for a long time, 
but had not been interfered with j and best, perhaps, by a series 
of observations of auto-infection. When a diphtheritic case 
has been in a room for some time, the room, bedding, curtains, 
and carpets are infected. The child is getting better, has a 
new attack, may again improve, and is again stricken down. 
Thus I have seen them die ; but also improve immediately 
after being removed from that room or house. If barely pos- 
sible, a child with diphtheria ought to change its room and bed 
every few days. 

The sick in crowded houses and quarters ought to be trans- 
ferred to a special hospital, which ought not to be too large. 
The Willard Parker Hospital, foot of East Sixteenth Street, 
New York, with its sixty beds for scarlatina and diphtheria, 
is in that respect a praiseworthy example. The large amount 
of good it is doing would grow in geometrical progression if 
there were, as there ought to be in a large and ambitious me- 
tropolis, half a dozen institutions of the same class. When 
diphtheria breaks out in a house, either private or tenement, 
the well must be removed to a healthy place ; in large cities, 
temporary homes ought to be provided for that purpose, to 
benefit the children of the poor. If the rich would but re- 
member that their children will be affected through the many 
links between them and the poor (servants, messengers, schools, 

British Medical Association, last August. Though the former essay has 
been copied in a number of journals of the country, this series would not 
be complete without due reference to the treatment of a disease which has 
established itself as a permanent scourge among us, and constantly baffles 
the best-directed efforts of the most thoughtful and skilful practitioner. 



INFECTIOUS DISEASES. 181 

dresses brought home from the tailor or seamstress, or pur- 
chased in the stylish and expensive establishments which give 
out the work to tenement working-people), their very egotism 
would compel them to do in the public interest what humanity 
does not urge them to perform. The sick must be reported to the 
health boards. The well children of a family with diphtheria 
must not go to school or church before a fortnight — the possi- 
ble period of incubation — has elapsed since their last contact 
with the sick. Schools must even be closed now and then, 
when an epidemic makes its appearance ; teachers instructed 
in the examination of throats. The condition of the house is 
to be examined into and improved ; attendants, servants, nurses 
and cooks, seamstresses and laundresses, teachers, shopkeepers, 
restaurateurs, barbers, hair-dressers, with their mild diphthe- 
ritic attacks and strong pecuniary interests, are frequent sources 
of infection. In times of common danger, public places, thea- 
tres, ball-rooms, dining-halls, public vehicles, hackney-coaches, 
and railroad-cars must be superintended by the authorities. 
There must be no clashing permitted between the public good 
and the individual money-bag. Clothing, bedding, room, and 
house must be thoroughly disinfected; articles used in the sick- 
room burned or soaked in a disinfecting fluid in the room, not 
carried over the house in a dry state ; the rooms thoroughly 
disinfected after a case terminated favorably or unfavorably ; 
the corpse disinfected, the funeral private, nothing removed 
from the house unless disinfected, no pieces of carpet thrown 
away to be picked up by beggars, no mattresses benevolently 
donated to the unsuspecting poor.* 



* To what extent contagion will prove dangerous, a case which was 
reported to me lately shows as well as anything I ever experienced. Un- 
fortunately, I have not yet received the permission of my correspondent 
to mention names, but the facts speak loud enough. The communication 

I refer to came from , Kansas, a few months ago, and is as follows : 

..." The water used by the family is of the best quality, the drainage 



182 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

The rules for disinfection, published by the National Board 
of Health in its Bulletin No. 10, of September 6, 1879, are 
still classical, very much more so than the suppression of that 
beneficent board — which might have proved a lasting blessing 
to the whole commonwealth — in this our surplus-ridden coun- 
try, from motives of ill-advised parsimony. I have copied 
them in my " Treatise on Diphtheria," Wm. Wood & Co., New 
York, 1880, and in the first volume, p. 698, of the " American 

perfect, and the hygienic surroundings perfect, as far as I can make out. 
There has never been an undoubted ease of diphtheria in the town, nor 
are there cases near here. The little fellow has not been away from home, 
nor have outsiders been at his home. 

"The case was at first tonsillitis, the result of exposure to cold. An 
abscess formed in one tonsil, and, after its rupture and discharge, the 
child had temporary relief. Up to this time there had been no particular 
systemic disturbance other than the tonsillar trouble would account for, 
nor were the voice and breathing affected any different from what would 
be expected in this disease. A day or so before the abscess broke, his 
mother thought swabbing the throat with alum-water might give him 
relief, and she proceeded to do this, using a sponge-swab that she had 
used in swabbing the throat in a case of diphtheria in her family in Chi- 
cago two years ago. Two days after using this swab laryngeal stenosis 
began to show itself, together with a profound systemic disturbance char- 
acteristic of diphtheria, and death resulted in three or four days from 
septic absorption and obstruction to breathing. Before I saw him his 
mother had applied some liniment over the angle of jaw, which produced 
a blister. No change was observed on this blistered surface until about 
the time the laryngeal stenosis began to show itself, when a tough gray- 
ish membrane, closely adherent to the underlying surface and bleeding 
when detached, — which was done with difficulty, — showed itself. The 
urine showed by ordinary test about one-fourth albumin. I cannot 
account for the trouble in any other way than through the swab used. 

" The family moved from Chicago to Detroit, where they lived six 
months before coming here last February, carrying the swab with them 
on their travels. There can be no doubt but that the case in Chicago on 
which the swab was used was one of diphtheria. Diphtheria was epidemic 
in the part of the city in which they lived, and the diagnosis was made by 
an able physician. About one-third of those attacked in this epidemic 
died." . . . 



INFECTIOUS DISEASES. 183 

System of Medicine." They may not be accessible to some of 
my readers, and will be welcome to all. 

" Instructions for Disinfection. 

" Disinfection is the destruction of the poisons of infectious 
and contagious diseases. 

" Deodorizers, or substances which destroy smells, are not 
necessarily disinfectants, and disinfectants do not necessarily 
have an odor. 

" Disinfection cannot compensate for want of cleanliness nor 
of ventilation. 

" I. Disinfectants to be employed. 

" 1. Roll-sulphur (brimstone) for fumigation. 

" 2. Sulphate of iron (copperas) dissolved in water in the 
proportion of one and a half pounds to the gallon ; for soil, 
sewers, etc. 

" 3. Sulphate of zinc and common salt, dissolved together 
in water in the proportion of four ounces sulphate and two 
ounces salt to the gallon ; for clothing, bed-linen, etc.* 

" II. How to use disinfectants. 

" 1. In the sick-room. — The most available agents are fresh 
air and cleanliness. The clothing, towels, bed-linen, etc., 
should, on removal from the patient, and before they are 
taken from the room, be placed in a pail or tub of the zinc 
solution, boiling hot, if possible. 

"All discharges should either be received in vessels ^contain- 
ing copperas solution, or, when this is impracticable, should 

* Carbolic acid is not included in the above list, for the following 
reasons : It is very difficult to determine the quality of the commercial 
article, and the purchaser can never be certain of securing it of proper 
strength ; it is expensive when of good quality, and experience has 
shown that it must be employed in comparatively large quantities to 
be of any use ; it is liable by its strong odor to give a false sense of 
security. 



184 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

be immediately covered with copperas solution. All vessels 
used about the patient should be cleansed with the same 
solution. 

" Unnecessary furniture, — especially that which is stuffed, — 
carpets, and hangings should, when possible, be removed from 
the room at the outset, otherwise they should remain for sub- 
sequent fumigation and treatment. 

" 2. Fumigation with sulphur is the only practical method for 
disinfecting the house. For this purpose the rooms to be dis- 
infected must be vacated. Heavy clothing, blankets, bedding, 
and other articles which cannot be treated with zinc solution, 
should be opened and exposed during fumigation, as directed 
below. Close the rooms as tightly as possible, place the sul- 
phur in iron pans, supported upon bricks placed in wash-tubs 
containing a little water, set it on fire by hot coals or with the 
aid of a spoonful of alcohol, and allow the room to remain 
closed for twenty-four hours. For a room about ten feet 
square, at least two pounds of sulphur should be used ; for 
larger rooms, proportionately increased quantities. 

" 3. Premises. — Cellars, yards, stables, gutters, privies, cess- 
pools, water-closets, drains, sewers, etc., should be frequently 
and liberally treated with copperas solution. The copperas 
solution is easily prepared by hanging a basket containing 
about sixty pounds of copperas in a barrel of water. 

" 4. Body- and bed-clothing, etc. — It is best to burn all arti- 
cles which have been in contact with persons sick with con- 
tagious or infectious diseases. Articles too valuable to be 
destroyed should be treated as follows : 

" a. Cotton, linen, flannel, blankets, etc., should be treated 
with the boiling-hot zinc solution ; introduce piece by piece, 
secure thorough wetting, and boil for at least half an hour. 

" b. Heavy woollen clothing, silks, furs, stuffed bed-covers, 
beds, and other articles which cannot be treated with the zinc 
solution, should be hung in the room during fumigation, their 



INFECTIOUS DISEASES. 185 

surfaces thoroughly exposed, and pockets turned inside out. 
Afterwards they should be hung in the open air, beaten and 
shaken. Pillows, beds, stuffed mattresses, upholstered furni- 
ture, etc., should be cut open, the contents spread out and 
thoroughly fumigated. Carpets are best fumigated on the 
floor, but should afterwards be removed to the open air and 
thoroughly beaten. 

" 5. Corpses should be thoroughly washed with a zinc solu- 
tion of double strength ; should then be wrapped in a sheet 
wet with the zinc solution, and buried at once. Metallic, 
metal-lined, or air-tight coffins should be used when possi- 
ble, certainly when the body is to be transported for any 
considerable distance." 

Prevention can accomplish a great deal for the individual. 
Diphtheria will, as a rule, not attack a healthy integument, be 
this cutis or mucous membrane. The best preventive is, there- 
fore, to keep the mucous membrane in a healthy condition. 
Catarrh of the mouth, pharynx, and nose must be treated in 
time. Many a chronic nasal catarrh, with big glands round 
the neck, requires sometimes but two or three regular salt- 
water injections (1 to 130) into the nose, and gargling, if the 
children be large enough to do so. The addition of one per 
cent, of alum will often be found useful. This treatment, 
however, must be continued for many months, and may re- 
quire years. Still, there is no hardship in it, and no excuse 
for its omission. The nasal spray of a solution of nitrate of 
silver, 1 to 500 or 1000, will accelerate the cure. Its applica- 
tion must be repeated every other day. Not infrequently has 
a treatment which was considered obsolete when I was young 
been of great service to me. It consists in the internal admin- 
istration of the tincture of pimpinella saxifraga. It is cer- 
tainly an efficient remedy in subacute and chronic pharyngitis 
and laryngitis. I generally give it to adults, diluted with 
equal parts of glycerin and water, a teaspoonful of the mixture 



186 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

every two or three hours, with the proviso that no water must 
be taken soon after; children in proportion. 

Large tonsils must be resected in times when there is no 
diphtheria. For during an epidemic every wound in the 
mouth is liable to become diphtheritic within a day, and 
such operations ought to be postponed, if feasible. The 
scooping of the tonsils, for whatever cause, I have given up 
since I became better acquainted with the use, under cocaine, 
of the galvano-cautery. From one to four applications to 
each side, or to the post-nasal space, are usually sufficient 
for every case of enlarged tonsils or lacunar amygdalitis 
(" tonsillitis"). It is advisable to cauterize but one side at a 
time, to avoid inconvenience in swallowing afterwards, and to 
burn from the surface inward. Cauterization of the centre of 
the tonsils may result in swelling, pain, and suppuration, 
unless the cautery is carried entirely to the surface; that 
means to say, the scurf must be on, or extend to, the surface. 
Another precaution is to apply the burner cold, press it on, 
and then heat. 

Nasal catarrh and proliferation of the mucous and sub- 
mucous tissue may require the same treatment, but in my ex- 
perience the cases which demand it are less frequent than those 
in which the tonsils need correction. 

The presence of glandular swellings round the neck must not 
be tolerated. They, and the oral and mucous membranes, affect 
each other mutually. Most of them could be avoided, if every 
eczema of the head and face, every stomatitis and rhinitis re- 
sulting from uncleanliness, combustion, injury, or whatever 
cause, were relieved at once. A careful supervision of that 
kind would prevent many a case of diphtheria, glandular sup- 
puration, deformity, or phthisis. 

For its salutary effect on the mucous membrane of the mouth, 
chlorate of potassium, or sodium, which is still claimed by some 
to be a specific in diphtheria, or almost so, is counted by me 



INFECTIOUS DISEASES. 187 

among the preventive remedies. If it be anything more, it is 
in a case of diphtheria an adjuvant. It exhibits its best effects 
in the catarrhal and ulcerous condition of the oral cavity. In 
diphtheria it keeps the mucous membrane in a healthy condi- 
tion, or restores it to health. Thus it prevents the diphtheritic 
process from spreading. 

Diphtheria is seldom observed on healthy, or apparently 
healthy, tissue. The pseudo-membrane is mostly surrounded 
by a sore, hypersemic, cedematous mucous membrane, to which 
it will then extend. Indeed, this hypersemia precedes the ap- 
pearance of the diphtheritic exudation in almost every case. 
The exceptions to this rule consist of those cases in which the 
virus may take root in the interstices between the normal ton- 
sillar epithelia, pointed out by Stoehr but a few years ago. 
Indeed, many cases of throat disease occurring during the 
prevalence of an epidemic of diphtheria are but those of phar- 
yngitis, which, under favorable circumstances, may develop 
into diphtheria. These throat diseases are so very frequent 
during the reign of an epidemic, that in my first paper on 
diphtheria (Amer. Med. Times, August 11 and 18, 1860) I 
based my reasoning on two hundred cases of genuine diph- 
theria, and one hundred and eighty-five of pharyngitis without 
a visible membrane. 

These cases of pharyngitis, and such of stomatitis and phar- 
yngitis accompanying the presence of membranes, are benefited 
by the local and general effect of chlorate of potassium. The 
surrounding parts being healthy or returning to health, the 
membrane remains circumscribed. The generally benign char- 
acter of purely tonsillar diphtheria, which is apt to run its full 
course in from four to six days, has in this manner contributed 
to secure to chlorate of potassium the undeserved reputation of 
being a remedy, the remedy, in diphtheria. The dose of the salt 
must not be larger than fifteen grains (one gramme) for an 
infant a year old, not over twenty or thirty (1.5 to 2) for a 



188 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

child from three to five years, in the twenty-four hours. An 
adult must not take more than one and a half drachms (six 
grammes) daily. These amounts must not be given in a few 
large doses, but in repeated doses and at short intervals. A 
solution of one part in sixty will allow a teaspoonful every 
hour, or half a teaspoonful every half hour in the case of a 
baby one or two years old. 

It is not too late yet to raise a warning voice against the 
use of larger doses. Simple truths in practical medicine do 
more than simply bear repetition : they require it. For 
though the cases of actual chlorate of potassium poisoning 
are no longer isolated, and ought to be generally known, 
fatal accidents will still occur even in the practice of physi- 
cians. When I experimented on myself, with half-ounce 
doses, thirty years ago, the results were some gastric and in- 
tense renal irritation. The same were experienced by Foun- 
tain, of Davenport, Iowa, whose death from an ounce of the 
salt has been impressively described in Alfred StillS's "Ma- 
teria Medica," from which I have quoted it in my treatise on 
diphtheria. His death from chlorate of potassium induced me 
to prohibit large doses as early as 1860. In my contribution 
to Gerhardt's Handbuch der Kinderkrankheiten, vol. ii., 1877, 
I spoke of a series of cases known to me personally. In a 
paper read before the Medical Society of the State of New 
York in 1879 {Med. Record, March 15), I treated of the sub- 
ject monographically, and alluded to the dangers attending the 
promiscuous use of the drug, which has descended into the 
ranks of domestic remedies ; and finally, in my treatise (New 
York, 1880), I collected all my cases and the few then re- 
corded by others. Since that time the recorded cases have 
become quite numerous, and less than a year ago a few new 
ones were related before the Practitioners' Society of New 
York. The facts are undoubted, though the explanations may 
differ. The probability is that death occurs from methsemo- 



INFECTIOUS DISEASES. 189 

globlnuria produced by the presence of the poison in the blood, 
though Stockvis, of Amsterdam, has tried, by a long series of 
experiments, to fortify my original assumption that the fatal 
issue was due to acute nephritis. 

There is, in every individual case, a certain danger, which, 
though it be common enough in other exhausting diseases, 
is of particular moment in diphtheria, where it is most fre- 
quent. It can be averted by meeting it early. It is heart- 
failure. Where it has occurred, the indications for treatment 
become as clear as they are urgent and often futile. When 
it is simply feared, a preventive treatment will save many a 
case. 

Heart-failure is usually developed gradually. It is fore- 
shadowed by an increasing frequency and weakness of both 
heart-beats and pulse, by an occasional intermission, by un- 
equal frequency of the beats in a given period (say of ten 
seconds), or by the equalization of the interval between systole 
and diastole, and diastole and systole. This latter condition, 
which is normal in the embryo and foetus, is always an ominous 
symptom. 

Heart-failure is due, besides the influences common to every 
disease and every fever, to tissue changes in the myocardium, 
in the nerves, or both. These changes may be due to the ill- 
nutrition of the tissues resulting from every septic condition of 
the blood, or specific alterations due to the diphtheritic process. 
Failure may either come on after having given warning, or it 
may be on you without any. Thus, there is no case of diph- 
theria — beyond, perhaps, those of the mild tonsillar form — but 
ought to make us anxious and afraid. Indeed, there is no 
safety and no positive prognosis until the patient is quite re- 
covered, and even advanced beyond the period in which 
paralysis may develop. 

Whatever enfeebles must be avoided ; absolute rest must be 
enjoined. The patients must be in bed, without excitement of 



190 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

any kind ; take their medicines — which ought to be as pala- 
table as possible — and their liquid food, and evacuate their 
bowels, in a recumbent or semi-recumbent position ; crying 
and worrying must be prevented; the room kept airy and 
rather dark, so as to encourage sleep if the patient be rest- 
less; and restless they are, unless they be under the influ- 
ence of sepsis, and thereby subject to fatal drowsiness and 
sopor. In no disease, except, perhaps, in pneumonia, have 
I seen more fatal results from exertion on the part of the 
sick, or from anything more than a sudden change of pos- 
ture. Unless absolute rest be enforced, neither physician nor 
nurse have done their duty. The latter must avoid all the 
dangers attending the administration of medicines, injections, 
sprays, and washes. Preparations for the same must be made 
out of sight, every application made quickly and gently. On 
no account must a patient be taken out of bed for that 
purpose. I know of children dying between the knees of 
nurses who called themselves trained and had a diploma. 

Pharmaceutical preparations, such as digitalis, strophanthus, 
sparteine, caffeine, besides camphor, alcohol, and musk, must not 
be postponed until feebleness and collapse have set in. These 
are at least possible, even probable; and this is certain, that a 
cardiac stimulant will do no harm. It is advisable to use it 
at an early date, particularly in those cases in which antipyrin 
or antifebrin are given. Besides, it is not enough that the 
patients should merely escape death ; they ought to get up, 
cito, tuto, etjucunde, with little loss and speedy recuperation ; 
a few grains of digitalis or their equivalent — preferably a good 
fluid extract — may or must be given in a pleasant and digesti- 
ble form daily. When a speedy effect is required, one or two 
doses of two or four minims each are not too large, and must be 
followed up by smaller ones. When it is justly feared lest 
the effect of digitalis be too slow, I give, with or without it, 
sulphate of sparteine. An infant a year old will take one- 



INFECTIOUS DISEASES. 191 

tenth of a grain four times a day as a matter of precaution, 
and every hour or two hours in an emergency. 

Of the same importance are alcoholic stimulants. The ad- 
vice to wait for positive symptoms of heart-failure and col- 
lapse before employing the life-saving apparatus is bad. There 
are cases which get well without treatment, but we do not know 
beforehand which they will be. No alleged mild case is safe 
until it has recovered. When heart-failure has once set in — 
and often will it occur in apparently mild cases — our efforts 
are too often in vain. Thus alcoholic stimulants ought to be 
given early and often, and in large quantities, thoroughly di- 
luted. There is no such thing as danger from them or in- 
toxication in septic diseases. A few ounces daily may suf- 
fice; but I have often seen ten ounces daily of brandy or 
whiskey save children who had been doing badly with three 
or four. 

Caffeine, or, in its stead, coffee, is an excellent cardiac tonic, 
except in those cases in which the brain is suffering from 
an active congestion. For subcutaneous injections the sali- 
cylate (or benzoate) of caffeine and sodium, which readily dis- 
solves in two parts of water, is invaluable for emergencies, 
in occasional doses of from one to five grains in from two 
to ten minims of water. From five to twenty grains of cam- 
phor may be given daily, as camphor-water, or in a muci- 
laginous emulsion, which is easily taken. It does not so dis- 
turb the stomach as carbonate of ammonium is apt to do. 
For rapid effect it may be administered hypodermically, in 
five parts of almond oil, which is milder and more conven- 
ient than ether. Strychnine may be added regularly from 
the beginning of failure, but mainly in cases with little in- 
crease of temperature. Its effect is more than momentarily 
stimulating. A child of three years will take a one-hun- 
dredth of a grain three times a day, and more in an urgent 
case. But the very best internal stimulant in very urgent 



192 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

cases is Siberian musk. I prefer to give it from a bottle, 
in which it is simply shaken up with a thin mucilage. In 
urgent cases it ought to be given in sufficient doses and at 
short intervals. When ten or fifteen grains administered to 
a child one or two years old within three or four hours will 
not restore the heart's action to a more satisfactory standard, 
the prognosis is very bad. 

The local treatment of the pseudo- membranes of the fauces is 
a subject of great importance. To look upon them as an excre- 
tion which needs no interference, is incorrect. If it were pos- 
sible to remove or destroy them, it would be a great comfort; 
but they can be reached only in certain places, and just in 
those in which they do least harm. Pseudo-membranes on 
the tonsils are the least dangerous, for their lymph communi- 
cation with the rest of the body is very scanty. Thus almost 
all forms of tonsillar diphtheria are among the most benign, at 
least as long as the process does not extend. Most cases of the 
kind run their mild course in from five to seven days, and it 
is just these which have given rise to the many proposals of 
tearing, scratching, cauterizing, swabbing, brushing, and burn- 
ing. There are cases which do not show the harm done. The 
fact is, that neither the galvano-cautery nor carbolic acid, nor 
tannin and glycerin, nor perchloride or subsulphate of iron can 
be applied with leisure and accuracy to the very membrane 
alone, except in the cases of very docile and very patient chil- 
dren. In almost every case the surrounding epithelium is 
getting scratched off or injured, and thus the diphtheritic 
deposit will spread. Besides, the membrane of the tonsil is 
altered surface tissue (as it always is wherever the epithelium is 
pavement), and not deposited upon the mucous membranes, 
from which it might be easily detached. Whatever is done 
must be accomplished without violence of any kind. If nasal 
injections be found advisable, they can be made so as to wash the 
posterior pharynx and the tonsils sufficiently, and thus render 



INFECTIOUS DISEASES. 193 

the special treatment directed to the throat exclusively, useless. 
Besides, it is easier, meets with less objection, and gives rise to 
less exhaustion than the forcible opening of the mouth. This 
fact is of great importance, as I shall show in connection with 
the local treatment of the nasal cavity. Where it is possible 
to make local applications without difficulty, the membrane 
may be brushed with tincture of iodine several times daily, or 
a drop of rather concentrated carbolic acid. Of powders I 
know only one, the application of which is not contraindicated, 
— viz., calomel. Even this may irritate by its very form. 
Everything dry irritates and gives rise to cough or discomfort. 
Whatever has, besides, a bad taste or odor, such as sulphur, 
iodoform, or quinia, must be abhorred. But lately sugar has 
been recommended as a panacea, also table salt. Iodol will do 
better than either. 

For the purpose of dissolving membranes papayotin, or 
papain, has been employed. It is soluble in twenty parts of 
water, and may be injected, sprayed, or brushed on. I have 
used it in greater concentration, in two or four parts of water 
and glycerin, in the nose, throat, and through the tracheotomy 
tube, in the trachea. One of the irrepressible drug manufact- 
urers and advertisers pushes the claims of some modification 
of the drug, which he calls papoid. For the same purpose 
trypsin is preferred by others. The mode of its application 
appears to be the reverse of indifferent. But lately I have 
seen, in the practice of one of our best-known practitioners, 
papayotin applied in powder, which resulted in constant irri- 
tation of the throat, while the patient otherwise was con- 
valescent. The pharyngeal hyperemia and slight exudation 
disappeared when mild alum washes were substituted. 

Diphtheria of the nose is apt to terminate fatally unless ener- 
getic local treatment is commenced at once. This consists in 
persevering disinfection and cleansing of the mucous surface. 
The disinfecting procedure must not be omitted long, be- 

13 



194 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

cause general sepsis results from rapid absorption through the 
surface, which is supplied with lymph-ducts and small super- 
ficial blood-vessels to an unusual extent. Disinfectant injec- 
tions must be continued every hour, for one or more days. If 
they be well made, the consecutive adenitis, particularly that 
about the angles of the lower jaw, is soon relieved, and the 
general condition improved. But there are cases in which it is 
not the lymph bodies that are the main gates through which 
constitutional poisoning takes place, but the blood-vessels 
only. In the incipient stage of such cases the discharge from 
the nostrils is more or less sanguineous ; in them the blood- 
vessels, thin and fragile, carry the poison inward with great 
rapidity. 

In a few cases injections are unsuccessful. They are those 
in which the whole nasal cavity is filled with membranous 
deposits to such an extent as to require forcible removal. 
Sometimes it is difficult to push a silver probe through them. 
That procedure may be repeated, the probe dipped in car- 
bolic acid, or wrapped in absorbent cotton moistened with 
carbolic acid of fifty or ninety per cent. After a while in- 
jections alone will suffice. But now and then the develop- 
ment of pseudo-membranes is very rapid, a few hours suf- 
fice to block the nostrils again, and the difficulty is the same. 

The liquids which are to be injected must be warm and 
fairly mild. Solutions of chloride of sodium, two-thirds of 
one per cent., saturated solutions of boric acid, one part of bi- 
chloride of mercury, thirty-five of chloride of sodium, and five 
thousand of water, more or less, or lime-water, or solutions of 
papayotin, or a five-per-cent. solution of hyperoxide of hydro- 
gen, or a solution of hyposulphite of sodium, will be found 
satisfactory. From the selection of these remedies it is at 
once apparent that the object in view is partly that of washing 
out and dissolving, and partly of disinfecting. I have not 
mentioned carbolic acid, which may be used in solutions of 



INFECTIOUS DISEASES. 195 

one per cent, or less. Its employment requires care, for much 
of the injected fluid is swallowed, and proves a danger to chil- 
dren of any age, but mostly to the young. In a number of 
cases the brushing of the whole surface with oil of turpentine 
has been found to answer. 

Most of the syringes I find in my rounds are abominations. 
The nozzle must be large, blunt, and soft. After having rec- 
ommended for many years the common hard-rubber ear- 
syringe, the sharp end of which was cut off, I now use always 
a short stout glass syringe with soft-rubber mounting in 
front. 

When the children cannot, or must not, be raised, I employ 
the same solutions from a spoon, or a plain Davidson atomizer. 
These applications can thus be made while the children are 
lying down, every hour or very much oftener, without any or 
much annoyance. The nozzle must be large, so as to fit the 
nostril. A single spray on each side will generally suffice. I 
am in the habit of covering the common nozzle with a short 
piece of india-rubber tubing. 

For a day or two these injections of fluids' or spray must be 
made hourly. It is not cruel to wake the children out of their 
septic drowsiness ; for it is certain death not to do so. 

Injections of the nose are oftener ordered than judiciously 
made. Hundreds of times have I been assured that they had 
been made regularly, hourly, for days in succession. Still 
there was a steady increase of glandular swelling and sepsis. 
I never believe a nurse to have made them regularly unless I 
have seen her doing it. They will run up their syringe verti- 
cally and not horizontally ; the fluid will return through the 
same nostril. On the successful injecting or spraying of the 
nares hangs every life in a case of nasal diphtheria. I have 
long learned to look upon a neglect to tell at every visit 
how to make an injection, as a dereliction of duty. This may 
appear a trifling way, but it is a safe one. The nurse must 



196 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

be made to tell you that at every injection the fluid returns 
through the other nostril, or through the mouth, or is swallowed. 

The procedure is simple enough, and need not take more 
than half a minute for both nostrils. A towel is thrown over 
the child's chest up to the chin, and the child gently raised in 
bed by the person who is to make the injection. This person, 
sitting on the bed, steadies the patient's head against her chest, 
while somebody else holds the patient's hands. The syringe 
is introduced horizontally by the person sitting behind the 
patient, and gently emptied. No time must be lost in refilling 
and attending to the other side. When pain is complained of 
in the ears, more gentleness is required, or the spray, or pour- 
ing in from a spoon, or minim-dropper even, has to take the 
place of the injection. 

Many sins are committed in doing this very simple thing. 
The unfortunate little one is made to see all the preparations, 
and is worried and excited, and the necessary gentleness in the 
proceedings is neglected in too many cases. 

For the purpose of softening and macerating pseudo-mem- 
branes steam has been utilized extensively. Its inhalation is 
useful in catarrh of the mucous membranes, and in many in- 
flammatory and diphtheritic affections. On mucous mem- 
branes it will increase the secretion and liquefy it, and thus 
aid in the throwing off of the pseudo-membranes. Its action 
is the more pronounced the greater the amount of mucip- 
arous follicles under or alongside a cylindrical or fimbriated 
epithelium. Thus it is that tracheo-bronchial diphtheria, so- 
called fibrinous bronchitis, is greatly benefited by it. Children 
affected with it I have kept in small bath-rooms for days, 
turning on the hot water, and obliging the patient constantly 
to breathe the hot clouds. Several such cases I have seen re- 
cover with that treatment. Atomized cold water will never 
yield the same result. Nor have I seen the patent inhalers do 
much good. 



INFECTIOUS DISEASES. 197 

Still, where the surface epithelium is pavement rather than 
cylindrical, and but few muciparous follicles are present, and 
the pseudo-membrane is rather im merged in, and firmly co- 
herent with, the surface, — for instance, on the tonsils and the 
vocal cords, — the steam treatment is less appropriate. On the 
contrary, moist heat is liable in such cases to favor the exten- 
sion of the process by softening the hitherto healthy mucous 
membrane. Thus it takes all the tact of the practitioner to 
select the proper cases for the administration of steam, not to 
speak of the judgment which is required to determine to what 
extent the expulsion of air from the steam-moistened room or 
tent is permissible. 

Steam can be properly mixed with medicinal vapors. In 
the room of the patient water is kept boiling constantly over 
the fireplace, provided the steam is prevented from escaping 
directly into the chimney, on a stove (the modern self-feeders 
are insufficient for that purpose and abominations for every 
reason); over an alcohol-lamp, if we cannot do better; not on 
gas, if possible, because of the large amount of oxygen which 
it consumes. Every hour a tablespoonful of oil of turpen- 
tine, and perhaps also a teaspoonful of carbolic acid, is poured 
on the water and evaporated. The air of the room is filled with 
steam and vapors, and thus the contact with the sore surfaces 
and the respiratory tract is obtained with absolute certainty. 

The secretion of the mucous membranes is sometimes quite 
abundant under the influence of steam, but still more, like 
that of the external integuments, increased by the introduc- 
tion of water into the circulation. Therefore, drinking of 
large quantities of water, or water mixed with an alcoholic 
stimulant, must be encouraged. Over a thoroughly moist- 
ened mucous membrane the pseudo-membrane is more easily 
made to float and macerate. 

To evolve large volumes of steam the slaking of lime has 
been resorted to. It is both an old and effective procedure. 



198 THEKAPEUTTCS OF INFANCY AND CHILDHOOD. 

Not only is the object in view accomplished by it, but it is the 
best means of bringing lime into contact with the morbid sur- 
face. In a room in which lime has been slaked, everything 
is getting covered with it. Thus this method of profiting by 
the local effect of lime is decidedly preferable to the almost 
nugatory effect of lime-water. 

It was to fulfil the same indication of softening the pseudo- 
membrane, by increasing the secretion of the mucous mem- 
branes, that pilocarpine or jaborandi was highly recommended. 
Guttmann recommended it as a panacea in all forms of diph- 
theria. There is no doubt that the secretion of the mucous mem- 
branes is vastly increased by its internal application, and by 
repeated subcutaneous injections of the muriate or nitrate of the 
alkaloid, but the heart is enfeebled by its use. I have seen but 
few cases in which I could continue the treatment for a suffi- 
cient time. In many I had to stop it because after some days 
of persistent administration I feared for the safety of the pa- 
tients. Therefore, as early as the meeting of the American Medi- 
cal Association at Richmond, eight years ago, I felt obliged to 
warn against its indiscriminate use in diphtheria. Thus it has 
shared the fate of all the hundreds of remedies and methods 
which have been declared to be infallible, and found wanting. 

Diphtheritic adenitis, the swelling of the cervical glands 
near the angles of the lower jaw, to which I have alluded 
as an ominous symptom, points to nasal and naso-pharyngeal 
infection. The treatment consists in disinfection of the absorbing 
surfaces. 

Direct local treatment of the glands, if not entirely useless, 
is, at all events, of minor importance and efficiency. The ap- 
plication of an ice-bag of moderate size will render the best 
service. The use of one part of carbolic acid to ten of alcohol 
irritates both surface and patient more than they can do good. 
Inunctions may do some good by friction (massage) ; inunctions 
with some absorbable material in them may do a little better. 



INFECTIOUS DISEASES. 199 

The common iodide of potassium ointment is useless ; iodide 
of potassium in three or five parts of glycerin is more readily 
absorbed ; the same in equal parts of water, with a little ani- 
mal fat, and six or eight times its quantity of lanolin, gives an 
ointment which is so readily absorbed that iodine is found in the 
urine within a few hours. Iodoform may be utilized in the 
same way. Injections of iodoform in ether, which I suggested 
some time ago, are too painful. Mercurial inunctions, those 
of blue ointment, require too much time for any effect to take 
place. Oleates are too irritating locally ; a lanolin ointment 
would prove more satisfactory. After all, however, the readiest 
method of reducing the swelling of the glands, and improving 
the prognosis accordingly, is that of cleansing and disinfecting 
the field of absorption. The rare cases of suppuration in these 
glands require incision and disinfection. They are as ominous 
as they are rare, however. There is but little pus, as a rule, 
but one or many local deposits of disintegrated gland-cells and 
gangrenous connective tissue. The incisions must be exten- 
sive, the scoop and concentrated carbolic acid must be freely 
used. In these cases hemorrhages may occur, some of them 
very difficult to manage. I have seen some of them terminate 
fatally. In these carbolic acid must be avoided. Compression, 
actual cautery, and acupressure have rendered good service. 
Solutions of iron must be avoided, for the scurf formed is 
a shield, behind which deleterious absorption is going on 
constantly in such wounds, as it does in the uterus. 

The internal treatment of an average case of pharyngeal diph- 
theria can be made to combine the indications of both internal 
and local administration. Of a two-per-cent. solution of the 
hyperoxide of hydrogen, or a five-per-cent. solution of the hypo- 
sulphite of sodium, a teaspoonful may be given every two hours. 
Both of these remedies have been extolled. It is their misfor- 
tune that they have been praised as panaceas. For thirty years 
I have preferred the use of the tincture of the chloride of iron. 



200 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

It is an astringent and antiseptic. Its contact with the dis- 
eased surface is as important as is its general effect ; therefore 
it must be given frequently, in hourly or half-hourly doses, 
even every twenty or fifteen minutes. An infant of a year 
may take three or four grammes (one drachm) a day, a child of 
three or five years eight or twelve grammes (two or three 
drachms). It must be mixed with water to such an extent 
that the dose is half a teaspoonful or a teaspoonful ; a drachm, 
or two drachms, with a small quantity of chlorate of potassium, 
in four ounces, allows half a teaspoonful every twenty minutes. 
No water must be drunk after the medicine. As a rule, it is 
well tolerated. There are some, however, who will not bear 
it well. Vomiting or diarrhoea is a contraindication to perse- 
vering in its use, for nothing must be allowed to occur which 
reduces strength and vigor. A good adjuvant is glycerin, a 
better one than syrups. From ten to fifteen per cent, of the 
mixture may consist of it. Now and then, but rarely, it is 
not well tolerated neither. When diarrhoea sets in glycerin 
must be discontinued. Still, these cases are rare; indeed, 
the stomach bears glycerin very much better than the rectum. 
In connection with this remedy, I wish to make a remark 
of decidedly practical importance. I know quite well that re- 
covery does not always prove the efficacy of the remedy or 
remedies administered. But I have seen so many bad cases 
recover with chloride of iron, when treated after the method 
detailed above, that I cannot rescind former expressions of my 
belief in its value. Still, I have often been so situated that I 
had to give it up in peculiar cases. These are such in which 
the main symptoms are those of intense sepsis, I should say such 
in which the iron and other rational treatment was not powerful 
enough to prevent the rapid progress of the disease. Children 
with naso-pharyngeal diphtheria, large glandular swelling, 
feeble heart, and frequent pulse, thorough sepsis, and irritable 
stomach besides, those in which large doses only of stimulants, 



INFECTIOUS DISEASES. 201 

general and cardiac, can possibly promise any relief, are better 
off without the iron. When the circumstances are such as to 
leave the choice between iron and alcohol, it is best to omit the 
iron and rely on stimulants mostly. The quantities required 
are so great that the absorbent powers of the stomach are no 
longer sufficient for both. 

Nor is iron sufficient or safe in those cases which are pre- 
eminently laryngeal. To rely on iron in membranous croup 
means waste and danger. 

In this latter form of membranous croup, diphtheritic laryngi- 
tis, or laryngeal diphtheria, the most useful internal remedy is 
mercury. Empiricism has often praised calomel in small and 
large doses. My acquaintance with mercury in this connec- 
tion is not at all new. Five years ago I published (Med. 
Record, May 24, 1884) a number of cases which got well under 
its use; at the same time that Dr. Thallon, of Brooklyn, pub- 
lished an article on the same subject. Since I have employed 
it (I prefer the bichloride), my conviction of the utter useless- 
ness of internal medication in laryngeal diphtheria, so-called 
pseudo-membranous croup, is thoroughly shaken. Until about 
six years ago I felt certain of a mortality of ninety or ninety- 
five per cent, of all the cases not operated upon. These figures 
were not taken from small numbers, for I compared those of 
others with my own. The latter are not a few neither ; for 
within the last thirty years I have tracheotomized nearly six hun- 
dred times, have assisted at as many more operations, and have 
seen at least one thousand cases of laryngeal diphtheria which 
were not operated upon at all. During the last six years I 
have seen no less than two hundred cases, perhaps many more. 
Among them recoveries have not been rare at all, at all ages, 
from four months upward. The uniform internal medication 
consisted in the administration of a dose of the bichloride every 
hour. The smallest daily dose ever given by me in the begin- 
ning was fifteen milligrammes, one-fourth of a grain, to a baby 



202 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

of four months ; this was continued a few days, and the dose 
then somewhat diminished. Haifa grain daily may be given 
to children of from three to five years, for four or eight days 
or longer. The doses vary from one-sixtieth to one-thirtieth. 
They require a dilution of one in six thousand or ten thousand 
of water or milk. There is no stomatitis, gastric or intestinal 
irritation is very rare. It occurred in a few cases, but then it 
was found that the dilution had not been sufficient, one in two 
thousand or three thousand only. If ever it exist, small doses 
of opium will remedy it. 

The benefit to be derived from the remedy depends greatly 
upon the time of its administration. Tracheotomy or intuba- 
tion is required, as a rule, after days only, and can often be 
avoided if mercury be given in time. If the operation becomes 
necessary after all, the treatment must be continued diligently. 
Never have I seen so many cases of tracheotomy getting well, 
since 1863, as when the bichloride was being used constantly 
in 1882 and the seven subsequent years. Nor am I alone 
with these favorable results. There are dozens of practitioners 
in New York City with whose methods and results I am well 
acquainted, some of whom are connected with me, in some 
capacity or other, who confirm the above statements. 

My experience with the bichloride is mainly gathered in 
cases of laryngeal and bronchial diphtheria, so-called pseudo- 
membranous croup and fibrinous bronchitis ; it is there where 
it has been particularly effective. Still, but few of these were 
quite localized affections. Our cases of diphtheritic laryngitis 
are mostly descending, and complicated with either diphtheritic 
pharyngitis, rhinitis, or both. Not a few, mainly of the latter 
kind, exhibit constitutional symptoms of sepsis. Many such 
have also recovered. 

In any case of diphtheria there may occur conditions and 
complications which yield their own indications, and require 
the closest attention on the part of the practitioner. I need 



INFECTIOUS DISEASES. 203 

not here refer again to the frequent attacks of exhaustion and 
heart-failure, which carry off a multitude of patients, unless 
they be met in time. What I said in previous papers on heart- 
failure and its prevention (or treatment) holds good in diph- 
theria, if anywhere. Therapeutical nihilism destroys as many 
lives as any number of direct mistakes in dosing. 

Nephritis and pneumonia are frequent complications or con- 
sequences of diphtheria. The treatment of either of them re- 
quires no particular recognition in this place. Nor does oedema 
of the glottis yield indications differing from that occurring 
from other causes. Diphtheria of the skin and sexual organs 
requires disinfectant ointments. I have mostly relied on 
iodoform one part, in from eight to twelve of fat. 

Diphtheritic paralysis, though of various anatomical and 
histological origin, yields in all cases a certain number of iden- 
tical therapeutical indications. These are : the sustaining of 
the strength of the heart by digitalis and other cardiac tonics. 
A child of three years may take daily, for a month, three grains 
or its equivalent ; for instance, one grain of the extract. This 
is an indication on which I cannot dwell too much. Many of 
the acute, and most of the chronic, diseases of all ages do very 
much better by adding to other medications a regular dose of 
a cardiac tonic. It is true that it is a good practice to follow 
the golden rule to prescribe simply, and, if possible, a single 
remedy only, but a better one to prescribe efficiently. 

Besides, there are some more indications : mild preparations 
of iron, provided the digestive organs are not interfered with. 
Strychnia, or other preparations of nux, at all events. In 
ordinary cases a child of three years will take an eightieth of a 
grain three or four times a day. Local friction, massage of 
the throat, of the extremities, and trunk, dry or with hot water 
or oil, or water and alcohol ; and the use of both the inter- 
rupted and continuous currents, according to the known rules 
and the locality of the suffering parts, find their ready indica- 



204 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

tions. The paralysis of the respiratory muscles is quite dan- 
gerous ; the apncea resulting from it may prove fatal in a short 
time. In such cases the electrical current used for very short 
periods, but very frequently, and hypodermic injections of sul- 
phate of strychnia in more than text-book doses, and frequently 
repeated, will render good service. I remember a case in which 
these, and the occasional use of an interrupted current, and oc- 
casional artificial respiration by Silvester's method, persevered 
in for the better part of three days, proved effective. 

13. Rheumatism, 

Acute articular rheumatism is a frequent disease both in 
infancy and childhood. 

Since I made this statement fourteen years ago,* after ob- 
servations extending over more than twenty years, a few au- 
thors have accepted and verified it. . But the majority are still 
of the opinion, inherited from their predecessors, that infancy 
and childhood are immune or almost so. Thus it is only four 
years ago that Edlefsen reported to the German Congress for 
Internal Medicine {Transactions, 1885, p. 323) but eleven cases 
of acute rheumatism under five years, none of which was 
younger than two. The assertion that the disease is rare un- 
der four or under two years is frequently met with. 

Nothing can be more erroneous. The frequency of valvular 
diseases, mainly of the left side of the heart, in children of 
from four or five years to adolescence ought to suggest the 
frequency of rheumatism ; for but few of them are due to 
scarlatina, almost all are secondary to rheumatism, than which 
there is no more frequent cause of cardiac disorder. They 
cannot be claimed as congenital, for the fact that but few of 

* A. Jacobi, "Acute Kheumatism in Infancy and Childhood," 1875, 
in a series of American clinical lectures, edited by E. C. Seguin, M.D., 
vol. i. No. 2. 



INFECTIOUS DISEASES. 205 

the foetal diseases of the heart are found on the left side, and 
but a small number survive the first (or perhaps second) year, 
remains undisputed. Nor is the number of rheumatic cases 
limited to those exhibiting cardiac symptoms ; for though en- 
docarditis is of more frequent occurrence — compared with the 
number of cases — in children than the same sequela is observed 
in the adult (in whom from ten to twenty per cent, contract a 
permanent organic lesion of the heart), still there must be, 
and are, many cases of acute rheumatism which run their full 
course without terminating in heart-disease. In order to as- 
certain this, the heart must be watched in every doubtful case. 
Endocarditis is sometimes the first symptom of acute rheuma- 
tism in children, and precedes every other even in apparently 
mild cases, and pericarditis and myocardial changes are not 
rare. When the slightest symptom of chorea minor shows it- 
self, the heart must also be examined together with the joints, 
for there are those cases in which chorea is not the final de- 
velopment of rheumatism and rheumatic endocarditis, but the 
very beginning of the disease, and then referable to a rheu- 
matic affection of the spinal membranes. 

All of these remarks I believe to be opportune, because of 
the frequency of cases in which the persistent notion that 
rheumatism is a rare disease gives rise to an erroneous diag- 
nosis — the ubiquitous " dentition," " worms," " malaria," and 
il colds" — and false treatment. After all, a correct diagnosis 
is the foundation and sine qud non of sound therapeutics ; 
thus I shall, in this neglected instance, add a few words on 
the subject of diagnosis, which is sometimes quite difficult. 

Fever is a common symptom in small children j every physi- 
cal disturbance raises their temperature. In acute rheumatism 
it is often but slightly elevated ; it sometimes rises at irregular 
times, being now and then highest about noon. The swelling 
of the joints is apt to be very trifling and is often overlooked, 
the pain (either spontaneous or on pressure) may be very much 



206 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

less than that resulting from fatigue, rhachitis, syphilitic bone- 
disease, colic, or otitis. Thus in every doubtful case of dis- 
comfort or pain the joints and heart must be examined for 
rheumatism. The diagnosis of acute articular rheumatism 
becomes quite difficult when but a single joint is affected, either 
temporarily or through the whole course of the attack. Such 
a monarthritis is principally observed in the hip- or knee- 
joint, both of which are also the occasional seats of traumatic 
injuries or tubercular degeneration. Sometimes, after a week 
only or still later, the additional inflammation of other joints 
facilitates the recognition of the exact condition. The isolated 
inflammatory rheumatism fails also often to be recognized be- 
cause of its being denominated "growing pain." The latter 
term dates from the medical nomenclature of past centuries, 
and ought to have been dropped long ago. What has been 
called by that name is of various origin and nature. It may be 
a neurosis of a joint with or without an cedematous swelling. 
I have seen a number of such instances in children of both 
sexes, about the shoulder-, hip-, and knee-joint mostly. An- 
other affection which has been classed under the head of 
"growing pain" is epiphysitis and the congestive swelling of 
the intermediate cartilage of the long bones. It is a frequent 
occurrence, without a perceptible cause beside the physio- 
logical hyperemia required for normal growth, and liable to 
become pathological ; it is often noticed in the convalescence, 
or recovery, from infectious diseases, particularly scarlatina. 
Still, the large majority of attacks of " growing pain" mean 
rheumatism ; it is the failure to appreciate this fact that gives 
rise constantly to mistakes in diagnosis, and the neglect in the 
administration of both preventive and curative measures. 

The treatment of acute articular rheumatism has been quite 
unsatisfactory down to a modern time. A few of the indi- 
cations are furnished by the actual or alleged causes of the 
disease. By some it has been believed to be endemic, like 



INFECTIOUS DISEASES. 207 

cerebrospinal meningitis ; it is sure that certain localities have 
been known to harbor a great many cases at the same time. 
Thus, a change of residence, if practicable, ought to be re- 
sorted to, provided the individual case is but one of a great 
many in the same neighborhood. Contagion has now and 
then been presumed to cause the spreading of the malady; 
but the number of observations of the kind is but very limited 
indeed. Rheumatism is very apt to make its appearance dur- 
ing and after some of the most prevalent infectious diseases, 
such as diphtheria, scarlatina, typhoid fever, dysentery, and 
erysipelas. Therefore the greatest possible care bestowed on 
those sick with them will prove a powerful preventive of 
rheumatic fever. The blood has been found to be changed 
during the latter affection. According to many writers, both 
chemists and physicians, the alkaline condition of the blood is 
less pronounced. This change, or the actual prevalence of 
acid in the blood, has also been either proved, or assumed to 
exist, in cachectic conditions of many kinds, in fevers, uraemia, 
leucocythsemia, diseases of the liver, in poisoning with acids, 
lead and mercury, in pyaemia, typhoid fever, gout, and dia- 
betes. In them, as in acute rheumatism also, lactic acid has 
been found in an undue proportion. It is the same acid 
which has been found in over-exerted muscles; still, when 
introduced into the circulation, it never produced articular 
rheumatism. The diminution of the alkali of the blood 
would justify at once the administration, through the whole 
course of an acute rheumatism, of alkaline salts, and particu- 
larly potassium ; the latter is greatly diminished according to 
Beneke, who, besides its relative absence, looks upon the im- 
pairment of nerve-power and the accumulation of organic 
acids as the main factors in the pathogenesis of rheumatism. 

Sudden changes of temperature are certainly among the 
causes of acute rheumatism. Cold and moist weather, moist 
houses, exposure to wind and rain will bring it on. This effect 



208 THEEAPEUTICS OF INFANCY AND CHILDHOOD. 

may be immediate, and consists in the sudden suppression 
of the cutaneous circulation, or gives rise, by reflex action, 
to vaso-motor or trophic disturbances in the joints. Particu- 
larly is that so in those who have inherited a disposition. 
Such an inheritance is not at all infrequent. I have seen 
acute rheumatism in several children of a rheumatic father or 
mother. The treatment of such cases must be mainly prevent- 
ive. The tendency to be influenced by sudden changes of 
the surrounding temperature can be modified or removed by 
the systematic use of cold water. Children with disposition 
to rheumatism must have a daily cold wash, sponge, or bath. 
The former is the mildest mode of application. They may 
be rubbed down with a wet sheet, and afterwards with a 
warmed dry and coarse bathing towel. Those who have been 
strengthened by this procedure, or such as are stronger, may 
be sponged, or use a shower-bath for a few seconds, or a cold 
bath. These will be well tolerated and prove useful, when 
the surface, mainly of the extremities, becomes warm after a 
moderate dry friction. Such children as feel chilly after these 
applications, may begin their treatment with tepid water and 
alcohol (4-6 : 1). I ought to add here, that this treatment 
will accomplish its end best when throughout the rest of the 
day great care is used to protect the surface. A cold wash or 
bath, given to harden and strengthen, must be combined with 
warm clothing and bedding to protect. Nothing could be 
more injurious than the exposure of the surface to wind and 
rain. The bare knees and calves of the children of vain 
mothers are foolhardy provocations of the invasion of many 
of the serious diseases. 

The swollen and painful joints must be protected against 
the pressure of blankets or painful handling by raising the 
bedclothes, keeping the limbs in a basket of proper size (waste- 
paper basket), and covering them thickly with cotton. Well- 
covered splints add greatly to the comfort of the patient. 



INFECTIOUS DISEASES. 209 

When pain and swelling are unusually severe, the application 
of an ice-bladder or ice-cloth is advisable. Very young or 
anaemic children do not bear them long. Cold water will then 
take the place of ice-water or ice. A wet bandage, or pack, 
round the afflicted joint is often borne well and relished. It 
ought to be changed every hour or half hour. Very anaemic 
and neurotic patients prefer hot and dry applications, mainly in 
those cases in which the pain is the principal symptom com- 
plained of. To relieve the latter I cannot advise the sub- 
cutaneous injections of carbolic acid which have been rec- 
ommended; in very severe cases I have been compelled to 
administer a few drops of a solution of morphia hypodermically. 
As a rule, however, oleate of morphia or a mild solution (from 
two to four per cent.) of muriate of cocaine on the skin, a chlo- 
roform liniment brushed on, chloroform poured into the cotton 
surrounding the joint and retained by oil silk, or a very mild 
galvanic current will give some relief. 

The swelling of the synovial membranes and ligaments in 
retarded convalescence or chronic cases taxes the patience of 
both the sick and the physician. Vesicatories kept on for 
half an hour, and frequently repeated ; the wet bandage or 
pack snugly applied so as to compress gently ; compression by 
bandages, or collodion, gentle massage ; the galvanic current 
daily applied, find their indications in many and various cases. 
Iodine will come in for its share of usefulness. Beside the 
internal administration of the iodides (potassium or sodium, 
or both combined, in doses of grs. v to xx daily), the external 
applications will be found beneficial. The officinal ointment 
will act through the gentle handling and kneading necessitated 
by its use. Solutions of the iodide of potassium in glycerin will 
act better, but are inferior to the lanolin ointment referred to 
in a former article. Superior to all, however, is the appli- 
cation, twice daily, of one part of iodoform in from eight to 
fifteen of collodion or flexible collodion. It is brushed over 

14 



210 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

the swollen part copiously, and allowed to dry while the limb 
is kept absolutely at rest for ten minutes. Only such scales 
as get detached spontaneously may be removed ; otherwise the 
next application is made on top of the preceding ones. Very 
old cases, with chronic effusion into the joint, require aspira- 
tion and washing out. These manipulations have become safe 
in the hands of every physician who knows the use of soap 
and disinfectants on himself and his instruments since opera- 
tive surgery has availed itself of the immense progress made 
in pharmacological laboratories. 

Endocarditis demands absolute rest, both of the organ and 
the body. Every exertion will prove injurious. Thus an 
occasional dose of opium or bromide, or both combined, has 
a good effect. The application of an ice-bag to the cardiac 
region, or, when that proves too heavy, an iced cloth, acts very 
favorably indeed. But not every murmur means endocarditis ; 
it may be the result of muscular incompetency or irregular con- 
traction only, and quite temporary; it is sometimes observed 
in cases of but moderate severity, and mainly combined, or 
alternating with, or preceding chorea minor, which now and 
then makes its appearance in the very earliest period of acute 
rheumatism. Both chorea and endocarditis can be mitigated 
or prevented by early attention. If every case of incipient 
rheumatism were sent to bed, if no "growing pain" were 
allowed to be on the play-ground, or at school, many a life- 
long ailment and early death would be avoided. 

The temperature is but rarely high, or rather there are a 
great many cases of articular rheumatism in infants and 
children in which the temperature is as little elevated as the 
rest of the symptoms urgent. But there are such as yield 
temperatures of from 104° to 107° and more. It is in these 
that delirium and other cerebral symptoms, paralytic respiration 
and collapse, may make their appearance, and that the most 
efficient antipyretics must be employed. Among them the cold 



INFECTIOUS DISEASES. 211 

pack, as described in former papers, and applied to the trunk 
and lower extremities as far down as the knees, is the readiest 
and most effective. It is particularly indicated in the cases 
complicated with endocarditis; it is in these that antipyrin, 
acetanilid (" antifebrin"), and phenacetin will not always have 
a pleasant effect. All of them are inferior to the salicylate of 
sodium in regard to antirheumatic and antipyretic action. 
A child of three years may take from six to ten grains every 
two or three hours, for one or more days. This is the less 
dangerous the more the symptoms of overdoses are under- 
stood. When they appear (mainly the brain symptoms, tin- 
nitus, stupor, paralytic or interrupted, sighing, respiration) 
ample time is given for the discontinuation of the drug; a 
single large dose for the night, of from ten to twenty-five 
grains, succeeds better, sometimes, than the many smaller ones. 
As a rule, salicylate of sodium mitigates the symptoms of 
pain, swelling, and fever very soon. Many of the patients 
feel very much better after the lapse of a day ; then the doses 
may be diminished or administered at longer intervals. Longer 
than from three to five days it ought not to be given ; if no 
effect, or an insufficient one only, be obtained after that time, 
no further reliance need be bestowed on it. Then antipyrin, 
antifebrin, or phenacetin may accomplish what the salicylate 
failed in. In the same way salol, salicin, and cresotic and 
benzoic acids have been recommended. 

At the same time, particularly when there is a constant 
tendency on the part of the temperature to rise either perma- 
nently or periodically, sulphate (or another preparation) of 
quinia may be administered in one or two doses of from five to 
eight grains each. The most opportune time is the period of 
remission which mostly takes place in the morning. Alkaline 
salts may be given alongside the other medication, alkaline 
mineral waters, such as Seltzer or Vichy or bicarbonate of 
sodium, from a scruple to a drachm daily, or citrate of potas- 



212 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

sium, or the bitartrate; or one of the nitrates which have 
formerly been credited with almost a specific action. Vegeta- 
ble acids have been warmly recommended, such as citric acid. 
They take the place of alkaline salts, inasmuch as they are 
eliminated as carbonic acid. The iodides of potassium and 
sodium have been esteemed very highly, — -justly so, indeed, — 
particularly as the tendency to chronicity renders desirable the 
persistent effect of a powerful absorbent. Of the other reme- 
dies, which have been given for their alleged specific effect 
(colchicum, colchicin, veratrum, aconite), I have seen but little 
effect in acute rheumatism of infancy and childhood. They, 
too, render better service in the cases which have become 
or are fast becoming chronic. 

Gonorrheal articular rheumatism is not excessively rare 
among infants and children, though direct sexual intercourse 
be not frequent at that age. It is mostly confined to one or a 
few joints (knee, ankle, shoulder), and of subacute nature ; the 
effusion is liable to be excessive, and apt to be purulent. The 
latter condition, being dangerous partly to the joint, and partly 
through its tendency to infect the body, must be watched care- 
fully; for it is often the beginning, or part, of a general 
pysemia ; in a few instances I have seen the eye destroyed by 
panophthalmitis in twenty-four hours, and the child died, 
after weeks of suffering, of the general infection. The cause 
is often what may be taken for a common vaginal catarrh, but 
frequently is gonorrhoea. The long time the latter may be con- 
cealed, unchanged in its contagiousness, within the vagina of the 
adult, and the facility of communicating it to the young by direct 
contact or mediate communication through towels, bedclothes, 
etc., yield a clue to certain otherwise unexplainable cases. The 
treatment of the diseased vagina has its own indications. That 
of the joint affected with gonorrhoeal rheumatism must be 
more local than the average case. An aseptic puncture may 
be made for the purpose of ascertaining the contents of the 



INFECTIOUS DISEASES. 213 

synovial cavity. If there be pus, it must be removed and the 
cavity washed out, thoroughly disinfected, the limb rested on a 
spliut and gently compressed. If serum in large quantity, 
puncture may become necessary when other treatment becomes 
unavailing. Otherwise gentle but steady compression by 
bandages, with or without mercurial plaster underneath, or by 
iodoform collodion, are indicated; at the same time the use of 
salicylate of sodium and iodide of potassium and (or) so- 
dium must be continued a long time. 

During and after an attack of acute articular rheumatism 
there will be noticed, occasionally, small neoplasms on tendons 
and the insertions of muscles, fascise, and periosteum, varying 
in size, numbers, and sensitiveness, which consist of young 
connective tissue with numerous cells, last from a few days to 
several months, and give rise to but little elevation of temper- 
ature. Sometimes they are the very last, or only remaining, 
symptoms of the disease ; now and then a new endocarditis has 
been observed to make its appearance with them. This "nodu- 
lated rheumatism ," "rheumatismus nodosus," is more frequent 
in children than in adults ; the oldest patient in whom I have 
seen it was a boy of eighteen years. In his case the insertion 
of the occipital muscle was the principal seat of the nodules, 
dozens of which, from the size of a pea to a small hazel-nut, 
could early be distinguished. From syphilitic gummata, fibro- 
mata, gout, and cutaneous tubercles they can be distinguished 
easily. Special therapeutics for this form there is none. 

Peliosis rheumatica is the name of a peculiar form of more 
or less localized purpura. In some cases of rheumatism a 
large number of small subcutaneous and cutaneous hemor- 
rhages appear mostly on the lower extremities, and mainly 
round the joints. Now and then they are painful, but fre- 
quently not sensitive at all. In this they do not differ from 
common purpura. In a number of cases of peliosis the heart 
was not found affected ; and the inference has often been drawn 



214 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

that peliosis is no rheumatism at all. Indeed, purpuric hemor- 
rhages are often noticed in other infectious diseases (typhoid, 
measles, whooping-cough, pneumonia, Bright's disease, syphilis, 
mercurial ism), and not infrequently round the malleoli and joints 
in general (maybe in consequence of the impediment to circula- 
tion resulting from the smaller amount of subcutaneous fat and 
consequent tension of the integument in those regions), and in 
a number of instances the accompanying articular pains of such 
constitutional diseases are best explained by the presence of 
hemorrhages inside. Still, peliosis will sometimes appear quite 
early in acute rheumatism, and these are the cases which have 
been the reason why they were classified as a specific variety, 
and peliosis claimed to be a specific rheumatic affection. If so, 
it requires no special treatment ; but the structural condition of 
the walls of the blood-vessels (and insufficient innervation and 
the presence of specific bacilli ?), which causes the hemorrhages, 
indicates the early administration of roborants, cardiac stimu- 
lants through the whole course of the disease, and great caution 
in the doses and quantities of salicylate of sodium, which has 
rather a disposition to increase the hemorrhagic tendency. 

There are a great many varieties, or rather degrees, of peliosis, 
similarly to what we know to take place in purpura. Accord- 
ing to whether the hemorrhage takes place near the surface or 
in the deeper layers of the tissue, both the color and the massive- 
ness of the hemorrhage will differ. In some cases the result 
is an erythema, which has been called either papulosum or nodo- 
sum from the differences in the results of inspection and pal- 
pation. It is observed both in severe and mild cases of articular 
rheumatism ; it is somewhat raised above the level of the skin, 
sometimes deeply inserted and then circumscribed; and fre- 
quently found near the joints. In accordance with the indi- 
cations furnished by rheumatism us nodosus and peliosis no 
special therapeutics is required for this form. 

Chronic articular rheumatism is but rare in childhood. Mon- 



INFECTIOUS DISEASES. 215 

corvo reports the case of a girl of two and a half years, whose 
rheumatism began with an acute attack, became chronic, and 
was finally cured by the galvanic current administered for a 
long time in succession. The youngest case of mine, also a 
girl, was five years old. She was puny and feeble, and her general 
nutrition defective. A number of the large and small joints, 
particularly of the hands, were affected, and the tumefactions 
of the ends of the bones quite marked. There was neither an 
affection of the voluntary muscles nor the heart, and no disease 
of any part of the nervous system, which Mitchell (1831) and 
Charcot (1868) have found to be the cause of "arthro- 
pathia" swellings. The treatment is about the same resorted 
to in the same disease when met in the adult. Salicylate of 
sodium must be given in those cases only which exhibit acute 
exacerbations. Colchicum, aconite, iodides will take its place, 
and will be required for a long period. Small doses of arseni- 
ous acid, from one-three-hundredth to one-five-hundredth of a 
grain every two or three hours, will answer well. Warm 
baths, salt-water baths (cold or warm), and sulphur baths will 
improve many a case. So will " hydropathic" treatment, gal- 
vanism, and massage. Others will be benefited by dry heat, 
sand-baths. For external treatment a diluted tincture of iodine, 
iodoform ointment, iodoform collodion, or the iodide of 
potassium and lanolin ointment can render good service. Nar- 
cotics are seldom required. The best results are obtained by 
the protracted use of alkaline waters. From what little I have 
seen of chronic rheumatism in children, and the many cases of 
the same disease in the adult, I recommend strongly the use of 
a lithia water (from one-half to a pint of the Buffalo lithia 
water), to which is added from a scruple to half a drachm of 
the bicarbonate of potassium as a daily dose. 

Muscular rheumatism can be diagnosticated occasionally in 
very young children ; in those from six to twelve years it is not 
so very rare. Its nature and symptoms do not differ from 



216 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

those in the adult. The neck, back, and shoulders are most 
frequently affected. The best preventive is the habitual use of 
cold water. Diaphoretics are not very useful. Narcotic and 
stimulating liniments find their own indications. Oleate of 
morphia is of but little use ; in a severe case I have injected 
a small dose of morphia with immediate and permanent effect. 
The interrupted current acts promptly in one or more sessions. 
The salicylate, antipyrin, antifebrin, and phenacetin have a 
speedy effect, in proper doses frequently repeated. Semmola's 
experience in a severe case of neuro-muscular rheumatism is 
worth remembering. The case was that of a woman of forty 
years, who suffered from stiffness and pain in a shoulder and 
right arm, with good passive motility of the joint. After the 
pain had lasted several months, massage, electricity, quinia, and 
salicylic acid having proved inefficient, the patient was relieved 
in a few days by a few subcutaneous doses of one-twelfth of a 
grain of pilocarpin. 

In but rare cases the rheumatic process in the muscle as- 
sumes the character of an inflammatory affection. Then there 
is a hyperplasia of the connective tissue between the fibrillar, 
the muscle becomes hard and somewhat shorter, its electrical 
irritability grows less or disappears, the skin even participates 
in the process. Such a case I once observed in a boy of twelve 
years. He was never entirely relieved, but greatly improved 
by massage, warm bathing, a mild continuous current, and the 
internal administration of hydrargyrum bichloride. The treat- 
ment was continued for more than a year. 

14. Pertussis. 

The mortality from pertussis in New York City is as 
great as that from typhoid fever. Twenty-five per cent, of 
all the cases under a year terminate fatally; five per cent, of 
all those between the first and fifth year, and one per cent, of 
all those occurring after the fifth. Its mortality, however, is 



INFECTIOUS DISEASES. 217 

not the only danger, for not infrequently chronic laryngitis, 
pneumonia, emphysema, and the result of hemorrhages tak- 
ing place during the attacks, impair the health of the patient 
for many years or a lifetime. Thus the tendency of allowing 
whooping-cough to run its full course on the plea that it is a 
self-limited disease, or that every child must have its whoop- 
ing-cough, is certainly not justified. 

The prevention of whooping-cough, which is a specific and 
contagious disease, is certainly not easy, for the reason that 
contagion may take place very suddenly, and through the first 
and second stages of the disease, both of which extend over a 
large number of weeks. Contagion may take place, no matter 
whether the cause is to be looked for in the presence of micro- 
organisms or not, by means of the exhaled air, or mucus, or 
the masses brought up by vomiting. Prevention means pro- 
tection against the effects of all these factors. 

As the disease is spread by contagion only, isolation is an 
absolute necessity, difficult though it be. In public institu- 
tions it is impossible. Thus no patient ought to be admitted 
to, or allowed to remain in, a public school. Whooping-cough 
children must not even be permitted to congregate in large 
numbers, because the cases will become more severe by their 
mutually affecting each other. In one point only isolation is 
more effective in whooping-cough than in other contagious 
diseases, — namely, in this, that the disease does not appear to 
be carried by persons not thus affected. 

The air must be kept pure, uniform, and moderately warm. 
No wind or draft, however, must be permitted. Utensils 
must be kept clean and be disinfected, and the masses brought 
up by vomiting disinfected, destroyed, or removed. The 
mucous membranes must be kept in, or restored to, a healthy 
condition, particularly those of the mouth and respiratory 
organs. Thus no injudicious exposure must be allowed. The 
digestive organs have to be watched, the stomach must not 



218 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

be fall at any time, the bowels kept regular, the food be 
digestible. 

As long as the cause of the disease is not understood, and 
therefore no causal indication can be fulfilled, the object of 
treatment limits itself to this: to relieve the severity and 
diminish the number of the attacks, to procure quiet nights, to 
stop the vomiting, to shorten the course of the disease, and to 
prevent detrimental consequences. 

An important indication is that of treating a catarrhal or 
inflamed mucous membrane. It is quite possible that a sore 
mucous membrane only is capable of admitting the contagion 
of whooping-cough as it does that of other infectious diseases, 
for instance, diphtheria. Besides, by attending to the mucous 
membranes in time, the occurrence of serious complications, 
such as pneumonia, may be prevented. Catarrh of the mouth 
and pharynx ought to be treated with doses of chlorate of 
potassium of from half a grain to a grain in a teaspoonful of 
water every hour; and a large number of our expectorants 
find their ready indications in such cases. All of those which 
have a depressing effect must be avoided, particularly anti- 
monials. Even ipecac must be given in small doses only. 
Alkaline waters have a beneficial effect. The muriate of am- 
monia in doses of from half a grain to two grains every hour 
or two hours will liquefy the viscid secretion of the bronchial 
mucous membrane. In a state of evaporation, as described in 
a former essay, it may be inhaled. The inhalation of other 
agents, which have been recommended as expectorants, will at 
the same time act as germicides, so the vapors of benzol, of 
carbolic acid, and cresolin ; and the reputation obtained by 
gas-works in the treatment of whooping-cough is thus finding 
its ready explanation. 

The effect attributed to astringents in the treatment of 
whooping-cough is best explained by their action on the mu- 
cous membranes. Particularly alum and tannin have been so 



INFECTIOUS DISEASES. 219 

employed. Emetics have been recommended for the purpose 
of relieving the surfaces of sticky mucus difficult to remove. 
Sulphate of copper or zinc, ipecac powdered, or turpeth min- 
eral are the proper substances to be selected for that purpose. 

Schliep has seen good effects of the use of the pneumatic 
chamber in whooping-cough. He kept the children with their 
mothers or attendants in compressed air. In a few cases a 
few sessions of two hours each were sufficient to relieve the 
patients considerably. In a number of cases from twelve to 
twenty sessions were required. In all of them he claims de- 
cided effects, not only in the reduction of the number and 
severity of the attacks, but also in the duration of the disease. 
The explanation of the good effect is looked for as well in the 
increased amount of oxygen inhaled as in the diminution of 
the hyperemia of the mucous membrane. I believe the plan 
is a good one, particularly if it could be combined with the 
inhalation of turpentine. 

Cases exhibiting a severe degree of pharyngitis and laryngeal 
hyperemia, particularly in children who have suffered a long 
time from chronic inflammatory affections of the parts, will 
do well, as far as the local symptoms are concerned, under the 
use of the tincture of pimpinella saxifraga; a drachm dis- 
tributed over the twenty-four hours will be the proper dose 
for a child of from two to three years. 

Local treatment has been resorted to by many. The 
pharynx has been treated locally with a solution of quinia 
(Hagenbach), a two-per-cent. solution of resorcin (Moncorvo), 
a one- or two-per-cent. solution of nitrate of silver, a five-per- 
cent, solution of hydrochlorate of cocaine, of four- or six-per- 
cent, solution of bromide of potassium. Applications have 
also been made directly to the larynx of quinia mixed with 
bicarbonate of sodium in different proportions, of mild solu- 
tions of salicylic acid, and of powdered sulphur. Inhalations 
have been resorted to, besides those enumerated above, of sul- 



220 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

phurous acid, and extolled as highly as any of those which 
have been mentioned. If they prove anything, they and the 
great number of the remedies recommended for the same pur- 
pose speak for the difficulty encountered in the treatment of 
whooping-cough, and for the confidence of the practitioner in 
the patience and submission of his wards. Michael treats 
whooping-cough as a neurosis, with the same means he em- 
ploys against other neuroses attributable or attributed to nasal 
irritation. He claims that seventy -five per cent, of his cases 
of whooping-cough have done well when exposed to the in- 
fluence of quinia, bromide of potassium, benzol, tannin, bo- 
racic acid, salicylic acid, iodoform, cocaine, bicarbonate of 
sodium, or prepared chalk applied to the mucous membrane 
of the nares. 

The internal administration of chloral hydrate, or croton 
chloral hydrate, has been recommended by Lorey in 1879. 
The daily doses range from eight to fifteen grains. In all 
cases the attacks became less severe within a short time, but 
the disease itself was not shortened. Kennedy expresses him- 
self very enthusiastically about the effect of the remedy, which 
is given by itself or combined with the bromide of potassium. 
To procure an occasional good night, a single dose of from six 
to twelve grains has rendered me good service. 

The inhalation of chloroform, or, according to some, of 
ether, can be recommended in those cases in which convulsions 
have either occurred during severe attacks, or in which the 
interruption of the circulation is such that cerebral hemor- 
rhage or convulsions must be feared. In the case of a very 
young infant I have administered chloroform once every hour 
for every new attack during the course of a number of days in 
succession for that very purpose, with beneficial result. 

Quinia has been used both internally and externally by a 
number of authors of good repute. It was first recommended 
by Letzerich, who claimed to have found the cause of whoop- 



INFECTIOUS DISEASES. 221 

ing-cough to consist in the presence of a coccus which he in- 
tended to destroy by the action of quinia. That coccus 
has not been found to this very day, but still quinia has found 
favor for a number of reasons. Rossbach credits the drug 
with the power of relieving increased reflex irritability. Binz, 
however, attributes to it an antizymotic action. He gives as 
many decigrammes daily as the child has years, so a child of five 
years would take eight grains of quinia a day. He expects to 
find an improvement after two or three days, inasmuch as the 
attacks are said to become by that time shorter and less severe. 
Where it cannot be given internally, he administers it in sup- 
positories or in injections. Where the sulphate or hydrochlo- 
rate are not tolerated, the neutral tannate of quinia is selected 
instead, with this proviso, however, that the latter salt is much 
weaker than the former, and has to be administered in doses 
from two to three times as large. It has the advantage of 
being tasteless. In our own country it is particularly Forch- 
heimer, who reported ninety-seven cases as having been bene- 
fited by the administration of quinia. 

Antipyrin has been recommended for whooping-cough, 
since 1886, by Demuth, Sonnenberger, Moncorvo, Guaita 
Wendt, and many others, as almost a specific. Like all the 
other chemical relatives of chinolin, it destroys parasites out- 
side the organism. It has been claimed, or presumed, that it 
displays the same effect in it. Whether that is true remains 
to be seen. At all events, however, it is a powerful nervinum. 
It is claimed that it can be given with the same beneficial 
result in the beginning of the disease and in its most severe 
stage, and that the latter will terminate favorably in from four 
to five weeks after the beginning of the treatment. The 
dose is from a grain and a half to two grains three or four 
times a day for every year of the patient, with an occasional 
large dose for the night. 

Of all the medicines advised against whooping-cough I prize 



222 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

belladonna most highly. I have always returned to it after 
having discontinued it for the purpose of trying one after the 
other of the many remedies recommended during these thirty 
years. As early as 1861 I had occasion to express, in the 
American 3Iedical Monthly, the following opinion : 

" Belladonna is the most powerful remedy in whooping- 
cough. I scarcely remember a single case in which its ad- 
ministration, for years past, proved unsuccessful in shortening 
the duration of the process. The result obtained by me has 
generally been this : that a well-developed case of whooping- 
cough, after the diagnosis was made certain beyond a doubt, 
would last for only three or five weeks longer, instead of run- 
ning through its full course of months and quarters of a year. 
The effect is generally not a sudden one. Many cases in which 
belladonna is given from the first commencement will become 
worse for a short while, then remain at their height for some 
days or a week, and gradually improve in both the character 
and frequency of the attacks. In others the effect is percepti- 
ble from the days after their first administration ; the cases 
soon assuming a more favorable aspect. Such has been my 
uniform experience during the last five years, in each of which 
the children of this city have been suffering from a more or 
less severe epidemic. 

" My readers, many of w T hom doubtless have been in the 
habit of prescribing belladonna in whooping-cough with more 
or less marked success, need hardly be assured that I claim 
no priority. Belladonna has been recommended in this dis- 
ease for many decennia, and has just as long been objected to, 
as either useless or dangerous. I have touched upon the sub- 
ject because of my conviction that both the former objection 
and the latter fear are groundless. 

" Belladonna is well known readily to produce symptoms of 
poisoning. An amount of two and a half or three grains 
taken by an adult in the course of a day, of either root or 



INFECTIOUS DISEASES. 223 

extract, has the effect of dilating the pupils, causing a feeling 
of dryness in the throat, scintillation and giddiness, and 
even erythema of the skin. This latter effect is, however, not 
frequently seen in adults, while the effects on the pupil and 
brain are very common. It was therefore believed that, as 
nervous disorders are as common as they are dangerous in in- 
fantile age, these effects ought to counter-indicate its use; it 
was stated that it would cause congestion, sopor, acute hydro- 
cephalus, and idiocy ; and the practical consequence simply 
was that the dose of the remedy, when given at all in a case 
where it appeared to be indicated, was entirely too small. 
Thus, doses of a sixtieth, a forty-eighth, a thirtieth of a grain 
of extract of belladonna, repeated three or four times a day, 
were deemed sufficient and proper. These doses could not 
but prove unsatisfactory, and thus it happened that the remedy 
was misappreciated and given up. The doses, however, ad- 
ministered by me proved successful, because they were really 
sufficient. 

" Infants of six or eight months of age affected with whoop- 
ing-cough require a sixth of a grain of either the root or the 
alcoholic extract three times a day ; children of three or four 
years tolerate three doses, each of half a grain. These doses 
appear to be very large in proportion to those tolerated by 
adults, but it is a fact which can easily be verified, that the 
effect of belladonna on the pupil and brain will hardly ever 
be perceptible in children from these or smaller doses. The 
succession of belladonna symptoms in children differs, more- 
over, altogether from that in adults ; the erythematous and 
flushed appearance of the face and neck, sometimes even of 
the whole surface, is the first symptom in infantile age; 
whereas it is seldom observed in adults, or in cases of thorough 
poisoning only. Some of the old authors have advised the 
administration of belladonna to such an extent as to produce 
the first symptoms of poisoning ; others, however, have in- 



224 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

sisted on this practice being dangerous and wholly objectiona- 
ble. I, for my part, soon found that those children suffering 
from whooping-cough who exhibited general erythema from 
an apparent overdose recovered soon, while others, in whom 
no such symptom was observed, remained sick for a long time ; 
and continued experience has proved that the occurrence of 
this symptom is absolutely necessary for the full remedial 
effect. To obtain a cure in whooping-cough, the remedy must 
be given in a dose sufficient to produce erythema, or at least a 
flushed condition of the face, and, as it were, feverish appearance 
after every dose of belladonna. Thus the dose is to be grad- 
ually increased until this result is obtained. It is a remarka- 
ble fact that very young infants may take proportionately 
large doses : at all events, I do not remember a single case in 
which less than half a grain was taken in the course of a day. 
The prescriptions I have been in the habit of ordering are 
very simple ones. I either give the medicament as a pow- 
der, or have the extract dissolved and sweetened according to 
circumstances. 

"The administration of belladonna alone is indicated in 
such cases of whooping-cough as are not complicated with 
inflammatory affections of the respiratory organs. The latter 
take the lead in complicated cases as well in treatment as in 
the nature and gravity of the symptoms. This is so certain 
that, whenever a pneumonia coincides with or follows whoop- 
ing-cough, the peculiar sound of the cough of the latter will 
disappear, nor return before the inflammatory affection is 
removed. As this is, moreover, the most dangerous of the 
two, it requires attention before the other. As to bronchial 
and laryngeal catarrh, the former especially is a very common 
symptom in whooping-cough. Where it is but slight it may 
be considered as unimportant; where, however, it gives rise 
to fever or dyspnoea, it constitutes a further indication to 
interfere." 



INFECTIOUS DISEASES. 225 

The preparations mentioned above need not be the only ones 
to be relied on. The tincture of belladonna is a convenient 
remedy, inasmuch as the dose can be readily and gradually 
increased. A baby of two years may take three daily doses, 
the first of which may be six drops. If the flush be percep- 
tible within twenty or thirty minutes, that is the dose; if not, 
the number of doses must be increased to obtain the effect 
which must be obtained after every dose. After a few days 
larger doses are required ; there is no case but demands at 
least twice the amount of the original dose of belladonna 
within ten or twelve days, or before the disease disappears. 
Atropise sulphas may take the place of belladonna. A child 
of two years will probably begin with the five-hundredth 
part of a grain, to be given three times daily, and increased 
according to the rules stated before. 

Since that early time alluded to, Vogel speaks highly of 
the effect of belladonna, taking the dilatation of the pupils as 
a guide. * As I have mentioned, this effect is rather late in 
appearing in children, and is not required; indeed, it may 
become quite uncomfortable. Meigs and Pepper combine 
belladonna and alum. Evans, in the Glasgow Medical Journal 
of 1880, recommends the administration of a large dose first, 
to be followed by smaller ones afterwards, and there are not a 
few authors who have seen immediate good effect following 
the intended or accidental administration of a large, almost 
poisonous, dose. Indeed, the number of practitioners now 
relying on the effect of belladonna in whooping-cough is quite 
large, no matter whether they look for the beneficial action on 
the laryngeal and other branches of the pneumogastric nerve 
or on the medulla oblongata, or rely on its influence in modi- 
fying reflex action. 

Opium is spoken of favorably by a great many. I cannot 
recommend it for anything like regular administration, but it 
certainly has a good effect in procuring good nights when 

15 



226 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

given in a single dose. A grain of Dover's powder given to 
a child of two years, at bedtime, will at all events have the 
effect of procuring sleep. In a number of cases the combina- 
tion of opium and belladonna acts quite well. The antago- 
nistic effect claimed for these two drugs is not such as to inter- 
fere with the combination of their effects as sedatives. 

Netter (La Semaine lied., 1886, p. 321) recommends the 
oxymel scillse (No. 277 of the " National Formulary of Un- 
officinal Preparations") for whooping-cough, and prescribes it 
in the following manner : After having taken food between 
three and four o'clock, the child is given a teaspoonful every 
ten minutes; those under three years take four or five, those 
over three years six or seven, and adults seven or eight tea- 
spoonfuls in the course of an hour. Food is again permitted 
at seven o'clock. In this way the administration of the drug 
is continued. It is claimed that both the number and the 
frequency of the attacks become less, but nothing is said of 
the duration of the disease. 

I. Widowitz (Wien Med. Woch., 1888, No. 17) has em- 
ployed the same remedy in one hundred and forty-nine cases. 
Both the number and the severity of the attacks are stated to 
have become less after a single administration in fifty-nine; 
in twenty-four that result was accomplished after the second, 
and in nineteen after the third or fourth administration. In 
twelve per cent, there was no favorable result at all. The 
duration of the disease was not changed. M. T. Schnirer 
(Arch. f. Kinderh., 1889, p. 447) arrives at the same conclu- 
sions, and suggests therefore the combination of oxymel scillae 
with some antimycotic treatment. I should rather propose its 
combination with belladonna. 



DISEASES OF THE DIGESTIVE ORGANS. 227 

VI. 

DISEASES OF THE DIGESTIVE OEGANS. 

The indications for the therapeutics of the stomach, both 
dietetic and medicinal, are by no means simple and clear in 
every individual case. For it is difficult to make an exact 
diagnosis of the anatomical condition of the surface and the 
tissue of the organ, because of the frequent combination of 
various conditions. Indeed, the boundary line between a sim- 
ple dyspepsia and a gastric catarrh is perhaps never made out 
clearly. The epithelium of the mucous membrane does not 
belong to it exclusively, but spreads in the contiguity of the 
tissue into the muciparous and the peptic glands. Thus the 
inflammatory condition of the surface becomes at once a " pa- 
renchymatous" aifection, though it be possible that an uncom- 
plicated catarrh and an uncomplicated inflammation may have 
an occasional existence. This, however, will last but a short 
time, and unless a gastric catarrh, or a dyspepsia, or an intes- 
tinal irritation — for the intestine shares the peculiar anatomical 
condition of the epithelium of the stomach — be relieved at 
once, the merely functional or superficial disorder becomes 
organic and deep-seated. These changes may refer either to 
the tissue or the secretion. Inflammatory thickening, erosions, 
ulcerations, or (Moncorvo) dilatation of the stomach will be 
observed in a great many instances. The secretions become 
abnormal. The normal hydrochloric acid of the gastric juice 
is almost invariably diminished ; now and then a case will be 
found, but in older children only, in which it will be increased 
in quantity ; still, as a rule, it is wanting or but scantily sup- 
plied. Lactic acid, however, is produced in much larger 
quantities than the first stage of digestion requires, and with 
it acetic, butyric, and the rest of the fat acids. With this 



228 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

variety of changes the indications for treatment go hand-in- 
hand; others are suggested by the multitude of etiological 
factors. The direct paralyzing influence of heat, the imme- 
diate effect of irritant and bulky ingesta, and the poisonous 
effect of bacteria introduced in the food and rapidly multiply- 
ing render the intelligent and effective treatment of many of 
the cases which occur in the practice of every medical man a 
matter of great difficulty and responsibility. Nothing is more 
common, but less appropriate, than routine treatment directed 
against a variety of cases. 

The main cause of the diseased conditions of the digestive 
organs is to be sought for in improper food. Not even 
mother's milk will always agree with the baby ; cow's milk 
cannot possibly take its place as a legitimate and satisfactory 
substitute. Much less reliance can be placed on manufactured 
or home-made mixtures of unequal composition and doubtful 
quality. Children of more advanced years resemble adults in 
this, that they are endowed with more resistance to damaging 
influences. But the infant and young child are in constant 
danger of losing their physiological equilibrium by slight 
changes in feeding or the deterioration of foods. The readi- 
ness with which milk, which is indispensable as a food, will 
decompose, acidulate, and become indigestible, renders the 
greatest attention a necessity in the interest of prevention. 
That attention must be first directed to the differences be- 
tween cow's and woman's milk, which ought to be obviated as 
much as possible. The former contains more casein and fat, 
less sugar and chloride of sodium. Besides, the casein of 
cow's and woman's milk differ both chemically and physio- 
logically. That has always been so, and will be so, though a 
recent journal article declares the fact — or its assertion — a 
" bugbear." The former is less digestible, and its amount in 
the food given an infant must not be larger than one per cent. 
A large percentage (11-12) of fat is contained in every nor- 



DISEASES OF THE DIGESTIVE ORGANS. 229 

mal defecation of an infant fed on breast-milk, thus great care 
must be taken not to exceed the quantity of fat contained in 
this normal food when artificial feeding is resorted to. In- 
deed, to what extent fat administered in excess, and indiscrim- 
inately, is apt to produce diarrhoea, is best illustrated by the 
" fat diarrhoea" which has been a frequent topic for discussion 
in medical journals. Water, salt, and sugar must be furnished 
the infant in sufficient quantities. 

Water is often wanting in infants' and children's food, and 
its absence is the cause of dyspeps and anatomical changes in 
the digestive organs. Its role in the organism is very mani- 
fold. Besides its influence on general metamorphosis, it is 
required to assist in pepsin digestion. In artificial digestion, 
albumin is liable to remain unchanged until large quantities 
of acidulated water have been supplied. The very presence 
of peptones in the stomach requires water to facilitate their 
solution and absorption, as is best proven by the immediate relief 
felt by a draught of water taken during the precordial heavi- 
ness and discomfort experienced after a hearty meal. Infants 
and children — mainly the former — receive too little water. 
Whenever they are thirsty, both in winter and in summer, 
they are given milk, — that is, food; and many a case of dys- 
pepsia, with its results, could be obviated by adding plenty of 
water to the food. Excess of water is attended with less in- 
convenience or danger, for it is readily absorbed. 

On some former occasions, and lastly in "The Intestinal 
Diseases of Infancy and Childhood" (G. S. Davis, 1887, De- 
troit, Mich., p. 44), I have given the reasons why chloride of 
sodium ought to be added to most foods of infants and chil- 
dren. For instance, vegetable diet contains more potassium 
and less sodium than all varieties of milk, and milk of her- 
bivores more potassium than that of carnivores. Thus, cat's 
milk contains sodium 1 to potassium 0.76, woman's milk 
1 : 1, 13-4.4, and sheep's and cow's milk 1 : 5.6. The amount 



230 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

of salt contained in woman's milk depends greatly on the 
presence of salt in her food. Thus many a defective milk 
can be remedied by the mother or wet-nurse adding salt to 
her food. Particularly is that necessary in dyspepsia and 
gastric catarrh in the baby, one of the main symptoms of 
which is the presence of large and hard curds in the masses 
brought up by vomiting or evacuated by the rectum. The 
addition of chloride of sodium to milk impedes or delays the 
solid curdling by rennet, — a physiological fact which explains 
the usefulness of salt in every kind of infant food. For in 
vegetables, and mainly in farinacea, the disproportion of po- 
tassium and sodium is still more evident than in milks. 

The removal of a small portion of fat and casein, which 
gathers on the surface of boiling milk, is welcome, though the 
quantity thus withdrawn is too small. To diminish the per- 
centage of fat by allowing milk to stand is not permissible, 
because meanwhile acidulation will set in. The latter will be 
prevented by boiling, mainly through the expulsion of a large 
quantity (three per cent.) of gases (carbonic acid, nitrogen, and 
oxygen) contained in the milk when it leaves the udder. 
Parasitic growths are destroyed by boiling. Thus I have 
always advised to boil the milk destined for the use of a baby 
as soon as obtained, fill it hot into bottles, containing from 
three to six ounces, up to the corks, close them tightly, and 
preserve them inverted in a cool place. Whenever a meal is 
to be prepared, the milk thus preserved ought to be heated 
again up to or near the boiling point, — preferably in a water- 
bath. That process ought to be repeated perhaps several 
times a day ; while one bottle is being heated, the others may 
undergo the same procedure, for every boiling interrupts the 
beginning of lactic acid or other decomposition. The sterili- 
zation of milk in Soxhlet's apparatus, manufactured for that 
special purpose, and recommended and introduced in New 
York by A. Caille, is a still better contrivance. Milk properly 



DISEASES OP THE DIGESTIVE ORGANS. 231 

sterilized will keep one or more days, but for general use 
among those who cannot obtain or pay for the patented ap- 
paratus my method will suffice under ordinary circumstances 
and for people with the most ordinary intellect. 

A certain amount of starch is digested at the very earliest 
age, for saliva is secreted at that time. Its effect persists in 
the stomach as long as the percentage of hydrochloric acid in 
the gastric secretion does not surpass 0.06 ; within the first 
half-hour of the digestive process there is none at all but or- 
ganic (mainly lactic) acid only. Thus, though starch pass 
the oral cavity rather quickly, it will still undergo its change 
into dextrin in the stomach. In many abnormal conditions 
this digestive change lasts a still longer time; thus in fevers, 
severe gastric catarrh, and in dilatation of the stomach. 
These are the very conditions in which farinaceous foods are 
best tolerated, for the reasons that the diastatic effect of the 
saliva is not disturbed, and that albuminoids could not be 
digested because of the absence in these conditions of hydro- 
chloric acid (and pepsin). In all normal and many morbid 
conditions the presence of certain quantities of amylaceous 
foods has some more functions. Besides being nutritious in 
its own way, starch serves to dilate cow's milk, to reduce the 
percentage of the mixture in casein, to prevent the latter from 
coagulating in large masses, and thus to render it more digest- 
ible. The reasons why I prefer in most instances either barley 
or oatmeal, or in others gum-arabic or gelatin, may be studied 
in the above-mentioned book. Here it suffices to recall the 
mere facts, which I believe are becoming firmly established. 
It is a source of gratification to the writer to learn that he has 
not been wrong in his practice and teaching. 

Thus F. A. Hoffmann, in " Lectures on General Therapeu- 
tics," Leipsic, 2d ed., 1888, p. 223, says in connection with 
the rules on infant feeding, annually published by the New 
York Health Department, which he copies, " Unless woman's 



232 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

milk can be had there is a great danger in the probability that 
the sensitive intestinal tract be supplied with injurious ma- 
terial. For such is the very best cow's milk in the cases of 
very young infants, because the mixture of its constituents 
differs greatly from that in woman's milk, and its casein is 
less digestible. Both physicians and manufacturers have tried 
to compound substitutes for woman's milk, but those only the 
composition of which is known must be noticed by scientific 
men and recommended. Another requisite is this, that such a 
food must be within the means and understanding of everybody, 
and that a certain supervision be possible. Jacobi's treatise 
in Gerhardt's ' Manual of Pediatrics' will be found satisfac- 
tory by all those who desire to inform themselves of all we 
know. From my own experience, I confirm his recommenda- 
tions to dilute milk with barley or oatmeal water. At present 
the hope has been expressed that all this may be replaced 
by sterilization of milk, but in practice there will be many 
impediments and obstacles. Sterilization can have but one re- 
sult, — viz., remove the danger arising from the decomposition 
of milk. But, after all, it is cow's milk and not woman's." 

In order to be available, cow's milk must be fresh, and not 
yet acidulated. The difficulty of obtaining it has led to the 
introduction of condensed milk, mainly in large cities. It is 
certainly preferable to bad cow's milk. But its composition 
is not uniform ; though a number of the different preparations 
may be honestly made, there is a surplus of sugar, and there- 
fore condensed milk may be permitted in individual cases, 
though not advised as a general and regular food for infants. 
Theoretically, it is an improper food because of its constitu- 
ents; practically, it is known to give rise to digestive disorders 
and rhachitis. 

From what I have said I draw the conclusion that as long 
as a baby is not nursed by a healthy woman, the opportunities 
for acquiring some kind of gastric disorder are very numerous 



DISEASES OF THE DIGESTIVE OKGANS. 233 

indeed. Dyspepsia is therefore quite frequent. Its treatment 
consists in more or less abstinence, and in the regulation of 
diet. As the gastric contents of infants who have been brought 
up on artificial foods is liable to be very acid, alkalies in small 
doses, and frequently administered, have a good effect. Bis- 
muth may be added. When there is vomiting, it must be 
determined whether it is gastric, and from what cause. Those 
who have been in practice know too well how often they have 
seen meningitis taken for a gastric disorder, and how common 
is the occurrence of that symptom in the incipient stages of 
all kinds of inflammatory fevers. When all these and the 
local irritation of the stomach (brought on, for instance, by the 
presence of ascarides) and nephritis can be excluded, only then 
the vomiting ought to be considered as gastric only. Now 
and then abstinence only ; or the drinking of warm water, 
or warm mustard water, to facilitate vomiting ; or alkalies, or 
alkalies with bismuth; or resorcin to disinfect the contents; 
or dilute hydrochloric acid to correct the nature of the gastric 
acid ; or the washing out of the stomach with warm water, or 
with an alkaline solution, or with a solution of one or two per 
cent, of resorcin in water ; and, finally, after the stomach has 
been freed of its injurious contents, small doses of opium (from 
one-hundredth to a fortieth of a grain every hour, or its equiva- 
lent in morphia or codeia) will prove satisfactory. Protracted 
vomiting I have seen getting well with small doses of arseni- 
ous acid, from a thousandth to a four-hundredth part of a grain 
every hour or every two or three hours, according to the age 
of the patient or the individual indications of the case. Small 
doses of ice-water or, better still, small ice-pills repeated every 
five or ten minutes will answer in many instances. Efferves- 
cent drinks, iced, such as small doses of Apollinaris, Seltzer, or 
Vichy, or champagne, may do well in certain cases, but will 
do so less frequently and less happily than in most adults under 
the same circumstances. 



234 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

Iii acute gastric catarrh, when produced by injurious ingesta, 
these ought to be removed. If vomiting have not occurred 
spontaneously, or not sufficiently, it must be produced by the 
above-mentioned drinks, tickling the fauces, friction of the 
precordial region, ipecac, — the syrup is very often an unre- 
liable preparation, — or other emetics. In cases of great urgency 
only the subcutaneous use of apomorphia may be resorted to. 
Purgatives must not be given in the beginning ; large enemata 
will act more favorably. They may consist of warm water, 
warm water with antispasmodics, such as asafcetida, or stimu- 
lants, such as turpentine. After a day or two a purgative dose 
of calomel will answer. Fever, unless it be high, requires 
no special treatment; in urgent cases only antipyrin may be 
given, either by mouth or rectum or subcutaneously. Ten- 
dency to convulsions requires cold to the head, or cold applica- 
tions to the heart, which will reduce both the irritation of that 
organ and the temperature of the blood. A warm bath will 
often do good, mainly when the feet are warm, but the cus- 
tomary bathing and jostling and tossing of a baby in convul- 
sions do more harm than good. Thirst must be relieved by 
water, carbonic acid water, or water acidulated with hydro- 
chloric acid (1 : 3000-5000). 

No solid food. Milk must be given in small quantities 
only, diluted with water, or lime-water, barley-water, or upon 
Kudisch's plan (dilute hydrochloric acid 1, water 250, milk 500). 
Vomiting is to be treated on the plan detailed above, predomi- 
nance of acids by alkalies, constipation rather by calcined mag- 
nesia in small and frequent doses than by drastics. The aqueous 
tincture of rhubarb, in doses of from ten to thirty minims every 
few hours, will prove very satisfactory in many cases. 

Severe forms of gastritis — the corrosive, diphtheritic, and 
suppurative varieties — require cold applications to the epigas- 
trium, and opium in the most available form ; in the beginning, 
subcutaneously. The corrosive form demands neutralization 



DISEASES OF THE DIGESTIVE ORGANS. 235 

of the poison first : salt water for nitrate of silver, diluted acids 
(vinegar) for lye, alkali (chalk, magnesia, baking soda, soap) 
for acids, sulphate of sodium or oil for carbolic acid, egg, water, 
and milk for corrosive sublimate, etc. All of these require 
a total abstinence, which may be continued for more or less 
time. How long it ought to be endured depends on the con- 
dition of the patient and the good judgment of the medical 
adviser. Adults will bear it many days, and infants and 
children from twelve to thirty hours. If such an absolute 
rest be demanded longer than this period, nutritive injections 
into the rectum must take the place of the introduction of food 
into the stomach. Now the rectum and the rest of the large 
intestine digests no albumin and emulsionizes no fat, but it 
transforms starch into dextrin, and cane-sugar into grape-sugar. 
Finally, it absorbs peptones of every kind, egg, emulsionized 
fat, and starch. Starch-water injections are therefore more 
than merely soothing. Raw egg in salt water (table salt 7 : 
water 1000) or egg with a solution of ten or twenty parts of 
grape-sugar in one hundred of water (Ewald), with or without 
claret or brandy, — the latter never in a high percentage, — are 
easily absorbed. Water is received greedily. In all cases of 
rapid elimination of water by vomiting, or of utter exhaustion 
in gastro-intestinal catarrh with imminent thromboses in the 
small cerebral veins ( u hydrencephaloid"), the hourly or bi- 
ll ourly injection of water, or a very mild salt water, into the 
rectum in doses of an ounce or more will fill the blood-vessels 
and restore circulation. 

Chronic gastric catarrh is sometimes dependent on or inter- 
rupted by acute catarrh ; the attacks of the latter must there- 
fore be promptly relieved. The several causes of chronic 
gastric catarrh have their own indications. Both in adults 
and children venous congestion resulting from pulmonary or 
cardiac diseases will give rise to it; thus in many cases digitalis 
in small doses, continued a long time, will be the remedy or 



236 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

one of the measures of relief. Sedentary life must be avoided, 
school-hours and private lessons kept within reasonable limits, 
and regulated by the meals rather than that these should be 
controlled by the former. Masturbation must be watched : I 
have seen it to be the cause of gastric disturbances exactly as 
in adolescence. Diet and food want attention. Most children 
eat too much, and many too irregularly. Solid food is to be 
given but scantily; no sweets, no fat. Eating must be slow 
and mastication careful. Toasted bread or stale wheat bread, 
milk diluted with cereals or according to the muriatic acid 
plan, or " peptonized," — everything of moderate temperature 
or hot, — will answer. Slowness of digestion, with heavy sen- 
sation about the epigastrium, demands additional chloride of 
sodium, bicarbonate of sodium, effervescent alkaline drinks ; 
fermentation indicates resorcin, or creasote in doses of from 
one-quarter to one-half of a grain (minim). A few grains of 
salicylic acid diluted in large quantities of water (1 : 500-1000) 
may also be tried. Rhubarb and magnesium, rhubarb and 
bicarbonate of sodium, tinctura rhei aquosa, render excellent 
service. When there is a great deal of mucus, dilute hydro- 
chloric acid with small doses of pepsin are indicated. When 
the tongue is thickly coated, with eructations, chloride of am- 
monium with tinctura rhei aquosa ; the tendency to vomit and 
pain demands bismuth, in older children Carlsbad, Congress, 
or stronger (bitter) waters. These measures may be continued 
for a long period ; bismuth may be given indefinitely ; sulphate 
of zinc can be administered (doses from one-twenty-fifth to one- 
sixteenth of a grain every few hours) a long time, nitrate of 
silver (doses of one-thirtieth or one-fifteenth of a grain several 
times daily) for not more than a week in succession. 

Occasionally the irrigation of the stomach is resorted to 
with advantage. 

The therapeutics of dilatation of the stomach is indicated 
mostly by its etiology, and its success in an individual case 



DISEASES OF THE DIGESTIVE ORGANS. 237 

must depend on its causes, which may be numerous : over- 
feeding in general and with amylaceous material in particu- 
lar; rhachitis with consecutive muscular debility; voracity, 
imperfect digestion, and gas inflation ; catarrhal inflammation 
with diminished absorption ; general muscular incompetency, 
as in anaemia and convalescence; congenital imperfection or 
partial absence of muscular tissue in the wall of the stomach ; 
or peritoneal adhesions of the stomach resulting in triangular 
or quadrangular shape of the dilated organ. Many of these 
causes cannot be helped ; in those which are amenable to treat- 
ment, this is prominently that of chronic catarrh. 

Antifermentatives must be given, such as bismuth, nitrate 
of silver, calomel, and resorcin. The quantity of food taken 
at once should be small; the meals should be numerous. 
Nothing should be given that is apt to ferment, like fat and 
great quantities of starch. Large amounts of fluid should 
not be given. Milk in small quantities must be given often. 
Diarrhoea may require tannin and other astringents ; it depends 
upon the condition of the stomach ; indeed, most cases of con- 
secutive diarrhoea will be best treated by attending to the 
stomach. Raw beef is among those articles of food which 
are most easily digested, and beef peptones are very useful. 
Raw milk is not so easily digested as boiled. Peptonized 
milk is preferable in many cases. Rudisch's preparation will 
do well because of the ease with which it is digested. A 
bandage should be worn about the abdomen. The faradic 
and galvanic currents can be used with advantage. According 
to Ewald, electricity and massage accelerate the passage of 
chyme into the intestine. It seems to me, however, that it is 
questionable whether digestion was improved by them, for it 
may be that both of these applications resulted in premature 
opening of the pylorus, before the gastric digestion was fin- 
ished. Preparations of nux vomica — the tincture — or strychnia 
in three daily doses of from one-one-hundred-and-twentieth to 



238 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

one-sixtieth of a grain each will improve the muscular tone of 
the stomach. 

In nervous dyspepsia therapeutics must be simple, yet the 
effect is not very encouraging. Food must be digestible and 
copious. Purgatives should never be given ; enemata must 
take their place, if required. Bitter tonics, country and sea 
air, cold bathing or sponge-baths, electricity, one large elec- 
trode being applied to the stomach and another to the spinal 
column, are indicated. In these cases, which are not quite 
rare among older children, particularly those with early and 
obstinate chorea and other symptoms of anaemia and " neuras- 
thenia," mild preparations of iron are among the very best 
remedies, and must be continued a long time. 

Gastric ulceration, with or without hemorrhage, is not quite 
uncommon in children of from seven to thirteen years. Fatal 
hemorrhages have been observed even in infants. No matter 
whether the cause may be found in an embolic process, or a 
chronic catarrh of long standing*, or a local injury (caustic 
or foreign bodies, stones, a safety-pin in a baby of eight 
months), the circulation in the parts is interrupted and the 
normal alkalinity of the tissues destroyed. Thus these are 
constantly exposed to the injurious effects of the gastric acids, 
similarly to what occurs in the dead body when the effect of 
the acids on the non-secreting gastric surface results in soften- 
ing and perforation of the wall (" gastromalacia"). 

Thus the first indication is to keep the stomach and duodenum 
as alkaline as possible, at all events between meals. Now, the 
introduction of any food will give rise to the secretion of gas- 
tric juice, which is acid, first by lactic, afterwards by hydro- 
chloric acid; a certain amount of these is required for normal 
digestion. Whatever there is, however, in the stomach of un- 
necessary acid or acids, which are not required for the physi- 
ological process, particularly the acetic, the butyric, caprylic, or 
only an excess of lactic acid, must be neutralized. An occa- 



DISEASES OF THE DIGESTIVE ORGANS. 239 

sional close of an antacid is not sufficient for that purpose, but 
it must be given regularly, and for a long time. I generally 
give the doses at intervals of two hours. I also give a dose a 
few minutes before each meal to neutralize every abnormal acid, 
no matter whether the patient is an adult or a child. 

Which antacid is to be selected, — the potassium, sodium, cal- 
cium, or magnesium salts? Of the latter, I prefer calcined 
magnesium to the carbonate, as I do not wish the expulsion 
of free carbonic acid into the stomach. I use it frequently, 
but rarely (for a child) in larger doses than from eight to ten 
or twelve grains daily. A small part of this, say one grain, 
is taken every hour or two, before meals, mostly in water, 
which should not be too cold ; hot water is even better. More 
than that quantity is seldom tolerated, because of diarrhcea 
setting in ; still, its purgative effect is very welcome in patients 
suffering from constipation ; these may take larger doses. 
When the above quantity does not suffice to neutralize the 
acids, or it is feared that more magnesium will cause diarrhcea, 
it may be combined with the carbonate or the phosphate of lime. 
Sodium bicarbonate does not take the place of the calcium and 
magnesium so readily, inasmuch as it also appears to promote 
the secretion of gastric juice. Thus, in most cases, I use 
magnesium or calcium with or without bismuth, or such 
adjuvants, if any, as may appear to be indicated for other 
reasons. 

This medicinal treatment must be continued for weeks or 
months; without it I do not see gastric or duodenal ulcers 
getting well. 

The Carlsbad waters, and salines in general, owe their effect 
partly to the neutralizing and partly to the purgative influence 
they exert. 

The use of lime-water is in part an illusion, if given for 
the purpose of neutralizing the acid. It is a failure because 
it contains only a single grain to nearly two fluidounces of 



240 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

liquid. But when added to cow's milk in sufficient quantities 
(1 : 3-6) it certainly makes it more digestible. 

The very function of the diseased organ involves danger. 
Both the stomach and the duodenum should be kept as idle 
as possible, and their labor should be made easy. Undigestible 
food must not be given, and solid food must not be allowed. 
Most cases, in older children, tolerate boiled milk, strained oat- 
meal, barley gruel, stale wheat bread, and a few also raw beef. 
Some take nothing but boiled milk, or buttermilk, or kumyss. 
Many, particularly convalescents or adults, will tell you that 
they do not digest milk. That may be true, but then they 
gulped it down and it formed a large cheese-cake in the stom- 
ach that was not afterwards dissolved and digested. They 
must boil their milk in the morning and heat it several times 
during the day almost to the boiling point. They must add 
a small quantity of table salt to it, also, in case the stomach is 
very acid, some bicarbonate of sodium, or calcium, or magne- 
sium. They must not drink their milk, but pour it upon a 
plate and sip it with a spoon. Thus prepared, they will digest 
it, particularly when it is not quite cold. In fact, many require 
their meals warm or hot. 

For the purpose of easier digestion, milk may be peptonized, 
according to Fairchild's directions; or it may be rendered 
more digestible by the process recommended by Dr. Rudisch, 
or mixed with farinaceous decoctions as recommended above. 

With an alkaline condition of the surface and an innocuous 
diet, the ulcers have an opportunity to heal. Their recovery 
may be aided by the administration of nitrate of silver. A 
child may take from one-thirtieth to one-twentieth of a grain 
in a tablespoonful of distilled water four or five times a day, 
if possible, on a fairly empty stomach. Or a smaller quan- 
tity may be given in a pill with or without a small dose of 
opium, say one-sixtieth to one- fifteenth of a grain in each pill. 
Sometimes I give but a single dose at bedtime, in addition to 



DISEASES OF THE DIGESTIVE ORGANS. 241 

the alkaline treatment. Nitrate of silver must not be given 
beyond a reasonable time, to avoid argyria. 

The tincture of iodine, in doses of from one to three drops 
for the adult, of one-half to one drop to a child, well diluted 
with water, has often been recommended. Its action is prob- 
ably antifermentative here as in chronic gastric catarrh. 

When there is much pain and a great deal of acid or other 
secretion, opiates are indicated, mainly those which are very 
soluble. Chloral is tolerated badly. 

Bad cases require rest in bed, particularly those in anaemic 
girls (and women). 

The stomach will have a better opportunity to get well when 
at rest than when at work. Thus it becomes necessary, 
sometimes, to abstain from feeding by the mouth altogether. 
Rectal alimentation then comes in to great advantage. In 
conditions of such genuine starvation, the lymphatics are very 
greedy and absorption from the rectum is very active. 

Ulcer of the stomach, in both the young and old, being 
frequently associated with intense anaemia, the result, in these 
as in many other cases, is mistaken for the cause. Then iron, 
the great presumed panacea for anaemia, is often introduced 
into the stomach which cannot digest it, and in its attempts to 
do so, pain, ulceration, and danger are increased.* 

The therapeutics of constipation depends on its etiology and 
its degree. In no case should the diagnosis be made without a 
thorough examination, which must be manual in many. The 
abdomen may be painless, but it is mostly inflated. Faeces 
come away in large lumps or small and broken pieces. Liver 
and spleen may be displaced, the former turned in such a way 
as to protrude its edge and posterior surface. The abdominal 
veins may be enlarged, appetite diminished ; vomiting is sonie- 



*A. Jacobi, "The Intestinal Diseases of Infancy and Childhood," 
Detroit, 1887. 

16 



242 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

times met with, occasionally also attacks of diarrhoea which 
are the result of the irritation produced by the hardened faecal 
masses contained in the colon. 

Actual constipation must not be mistaken for an apparent 
one, which is observed in infants who have a movement every 
two or three days only ; the amount of faeces thus discharged 
is apt to be trifling. The baby is emaciated, atropine, not al- 
ways fretful. In him the scantiness of defecation is the result 
of lack of food, and the alleged costiveness is speedily rem- 
edied by the furnishing of a sufficient quantity of appro- 
priate nourishment. 

Among the foremost causes of constipation is mechanical 
obstruction, brought on by cystic and other tumors, imperfora- 
tion, hernia (pervious and incarcerated), intussusception and 
twisting of the intestine, or by a peculiar condition of the 
sigmoid flexure described by me in the Journal of Obstetrics 
of 1869, and lately in "The Intestinal Diseases of Infancy 
and Childhood," p. 184. There I have detailed the embryo- 
logical and anatomical facts connected with the subject, which 
ought to be well understood by this time ; for the cases of 
constipation, depending on the undue length of the descend- 
ing colon and the multiplicity of flexures which compress each 
other and thus obstruct the passage, are quite numerous in 
every physician's practice. These cases of constipation are apt 
to last up to the sixth or seventh year and require constant 
attention, but medicinal treatment ought to be avoided. The 
faeces may be so hardened and immovable as to necessitate 
their removal from the rectum by means of the finger or a 
spoon. On no account must purgatives be given as a regular 
thing, but an enema must be administered daily for many years 
in succession. At the above-mentioned age the relation of the 
several parts of the intestinal tract becomes more normal, and 
the necessity for mechanical interference ceases accordingly. 

An improper condition of food is a frequent cause of con- 



DISEASES OF THE DIGESTIVE ORGANS. 243 

stipation. Superabundance of casein is relieved by diminishing 
its quantity, by replacing the milk of a cow by that of a wet- 
nurse, the white and heavy one of a wet-nurse by the thinner 
and more bluish one of another woman, or by reducing the 
amount of casein in artificial food to one per cent. Besides, 
the milk thus reduced must be mixed with a glutinous (fari- 
naceous) substance; oatmeal, to remedy constipation, is prefer- 
able to barley or any of the rest. Large amounts of starch must 
be avoided. Milk and artificial food will often lose their con- 
stipating effect by the addition of cane-sugar. Babies at the 
breast are often cured of constipation by the administration of 
one or two teaspoonfuls or a tablespoonful of water, or oatmeal 
water, thoroughly sweetened, before each nursing. 

Many preparations kindly supplied by the ever- watchful 
and humanitarian trade contain large quantities of phosphates. 
They are apt to pass in part into the intestine undissolved and 
unabsorbed. So will large doses of bismuth. Thus constipation 
may follow their use. The treatment of such a case is plainly 
indicated ; likewise those which are the direct result of the 
administration of astringents and opiates. The omission of 
such medication is the first condition of a cure. 

Constipation is often dependent on the partial absence or 
the viscid condition of intestinal mucus. This is so in fevers, 
now and then in chronic (intestinal catarrh) enteritis; also 
when there is too large a secretion from the skin and (or) 
kidneys, and when too little water is introduced into the 
system. I have repeatedly emphasized the fact that most in- 
fants are given less water than they require. 

Incomplete peristalsis resulting in costiveness may depend 
on a morbid condition of either the muscle of both the in- 
testine and the abdominal wall, or its innervation. Early 
rhachitis shows its effect in producing muscular incompetency ; 
babies with regular evacuations after birth will become costive 
in their second and third month, and remain so although they 



244 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

are alleged to " look the picture of health." Not rarely rhachitis 
will make headway in muscles, epiphyses and diaphyses, even 
in cranial bones ; while the weight of the patient does not 
decrease, his skin feels soft though flabby, the limbs and trunk 
are rotund though bleached. Iudeed, there are many in whom 
constipation is the very first symptom of rhachitis. In all of 
them it is self-evident that constipation cannot be relieved 
permanently except by a thoroughly successful antirhachitical 
treatment. Sedentary habits of school-children have the same 
effect in producing constipation. It is relieved by change of 
habit and plenty of physical exercise, and additional fruit diet, 
but purgative medicines, given persistently, render these cases 
worse. The binding effects of chronic peritonitis, either general 
or local, must not be combated with purgatives ; a snug band- 
age round the abdomen gives support and tone to the bowels, 
and an enema, given every day for months in succession, pre- 
vents accumulation and its consequences (dilatation, disorder 
of circulation, septic absorption). Universal emaciation and 
atrophy resulting in constipation has its own indications, and 
chronic cerebral disease (hydrocephalus) may require such local 
and medicinal treatment as will be detailed further on. 

In all forms of constipation in infants or children few 
medicaments ought to be used. As there is so often an excess 
of acid in the gastric and even intestinal contents, calcined 
magnesia finds its twofold indication. It may be given in 
many small doses or a single large one which need not exceed 
five or ten grains a day. Doses of a grain or two grains may 
be continued for many days and repeated from three to six 
times daily. Rhubarb acts well when combined with it for 
the purpose of overcoming protracted costiveness. Rectal 
injections may be given from the common fountain syringe, 
the nozzle of which must be introduced beyond the two 
sphincters. In some cases it is desirable to introduce the 
instrument to a greater distance ; an elastic catheter attached 



DISEASES OF THE DIGESTIVE ORGANS. 245 

to the nozzle can be used for that purpose, but the very condi- 
tion of the sigmoid flexure, detailed above, renders the intro- 
duction of the instrument beyond the very beginning of the 
sigmoid flexure a perfect illusion. It happens quite often 
that an elastic or flexible tube, when introduced beyond the 
third sphincter, bends upon itself and reappears at the anus. 
To facilitate the entrance of the liquid into and beyond the 
sigmoid flexure the injection must be made gently and slowly 
while the pelvis of the infant is raised. 

To facilitate the downward movement of fsecal masses and 
to stimulate peristalsis, friction and kneading (massage) may 
be resorted to. Kneading must be performed with the palm 
of the hand, gently and persistently ; friction is best commenced 
in the right side and continued over the epigastrium and down 
the left side, in the course of the colon. Great caution and 
judgment must be used because of the frequency of local 
chronic peritonitis, which may give rise to subacute or acute 
exacerbations. 

Electricity has been used successfully when constipation 
was the result of insufficient peristalsis. E. Schillbach found 
that the several portions of the intestinal tract respond dif- 
ferently to the application of the faradic and galvanic currents. 
The latter appears to have a stronger effect than the former. 
Local contractions result from the negative pole (cathode), 
peristaltic waves from the positive (anode). Thus for the 
relief of chronic constipation depending upon incompetency of 
muscular action the former ought to be applied to the interior 
of the rectum, the latter over the abdomen, along the colon. 

In the cases of persistent constipation depending upon an 
insufficient muscular action of the intestine now and then 
medication may appear required. I have treated a number of 
cases of the kind with nux and (or) calabar, adding some 
purgative extract. A little boy with a decidedly rhachitical 
history, three years old, took three times a day a sixteenth of a 



246 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

grain of each — extract of mix vomica, extract of fab. calabar, 
and compound extract of colocynth — for many weeks in succes- 
sion. But cases of the kind must remain exceptional. As an 
occasional purgative, for the purpose of relieving the intes- 
tinal tract of indigestible and injurious masses, castor oil is 
probably the best and mildest; a few grains of calomel will 
act both as a purgative and antifermentative. The compound 
powder of liquorice will take the place of oil, when the latter 
is not tolerated, or is objected to ; also the fluid extract of 
rhamnus frangula. 

Among the drastics, all of Avhich are irritants, rhubarb and 
aloes are probably the mildest, and are tolerated a long time in 
succession. Of the salines, chloride of sodium is the simplest. 
Its main action is osmotic; besides, it occasions thirst and 
thereby induces the ingestion of a large amount of water. 
The continued use of salines irritates the mucous membranes. 
The combination of the sulphate of sodium with the sulphate 
of magnesium and chloride of sodium has a mild and happy 
effect. 

A frequent accompaniment of constipation is colic. Its 
causes are, beside constipation, fermenting food, gastrointesti- 
nal catarrh, the presence of ascarides in large numbers, reflex 
spasm produced by cold feet and chilled skin, diminished 
tonicity of the muscular layers of parts of the intestine (in 
general anaemia and rhachitis during early infancy), and, finally, 
chronic peritonitis, which resulted in adhesions, or such local 
changes in the walls of the intestine as will produce local con- 
tractions or dilatations. Thus as the etiology of colic varies so 
much, the treatment must vary in order to be rational and 
effective and adapt itself to the cause. Its symptomatic treat- 
ment will often require either an enema or a purgative medi- 
cine, antispasmodics or narcotics (assafcetida, opium); they 
are apt to give speedy relief. Gentle friction of the abdomen, 
the application of dry heat (flannel, hot plate, hot sand-bag), 



DISEASES OF THE DIGESTIVE ORGANS. 247 

and the administration of hot aromatic teas, freshly prepared 
(fennel, anise, catnip, German chamomile), a few drops of essence 
of peppermint in a teaspoonful of hot water, or the injection 
into the rectum of large quantities of aromatic teas, at a tem- 
perature of 100° or more, will do good ; great care must be 
taken lest atmospheric air enter the bowel. 

The predisposition of infants (and children) to diarrhoea! 
affections has been treated in a special chapter of my " Intes- 
tinal Diseases of Infancy and Childhood" (p. 190). Finding 
its explanation in anatomical and physiological facts, it demands 
no correction ; but has to be taken into account in every case 
of diarrhoea to avoid a misconception of what is normal in 
regard to both the number and consistency of evacuations. 

Diarrhoea is always dependent on, or connected with, surface 
changes of the intestinal mucous membranes, from a simple 
catarrh to ulceration. Catarrh may, be localized, but is gen- 
erally very extensive. It may descend from the stomach, 
ascend from the rectum and colon, or originate in any part 
of the small intestine. 

The treatment of diarrhceal diseases depends in part on the 
locality, in part on the etiology of the individual affection. 
No " specific" treatment will ever do good, not even the modern- 
ized stomach-pump sticking conceitedly out of the coat- 
pocket of the delighted medical man who appears eager to 
emulate the midwife of our mothers with the rectal syringe 
under her arm as her emblem. Thus, indeed, unless it be the 
intention to fill these pages with prescriptions to be copied 
thoughtlessly, nothing can be permitted here except general in- 
dications for treatment. My readers will have noticed that 
I have carefully abstained from prescription writing in these 
papers. They are written for my peers, and not for the very 
beginner who looks for the most advanced accomplishment 
in a formula, nor for those who like to be supplied with their 
medical brains by the loquacious agent of the manufacturer 



248 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

furnishing diagnosis, indications, formula, and medicine for 
doctors and mankind, from the ubiquitous satchel. 

The causes of diarrhoea are various. Food in improper 
quantity or quality, mostly improper artificial food, is among 
the principal causes. But even mother's milk may cause it, 
as is proven by the fact that there are babies who, while falling 
sick at the breast of one woman, may recover at that of another. 
Mothers who are sick or convalescing, or subject to very strong 
emotions, those who nurse too often, who suffer from tuber- 
culosis or syphilis, who are pregnant, some when they are 
menstruating, and all anaemic persons, secrete an improper 
milk. The colostrum secreted immediately after child-birth 
is apt to give rise to diarrhoea. Milk containing too much 
fat is the principal cause of what has been described as u fat 
diarrhoea," by German authors mostly ; that containing salts 
in superabundance, mainly in anaemia, is liable to produce 
the same effect. 

The amount of food introduced may be too large either 
absolutely or relatively; the latter when the secretion of 
gastric fluids is insufficient, thus facilitating gastric fermen- 
tation in place of digestion ; or when the flow and activity 
of pancreatic juice, limited at a very early age, is still more 
interfered with by a diseased condition of any kind, and fever 
of any description. 

The infant intestine is not controlled to the same extent as 
that of the adult by emotional influences; but local irritation 
is a frequent cause of diarrhoea, and the organ is very sensitive 
to the diminution or increase of atmospheric moisture and 
heat. It is quite probable that the overheating of the general 
surface has results similar in character to what are known in 
adults also, as the consequence of external combustion on the 
condition of the duodenum and the general nervous system. 

The mucous membrane with its lymph-vessels and glands 
is easily irritated by such results of fermentation as phenol, 



DISEASES OF THE DIGESTIVE ORGANS. 249 

indol, skatol, bacteria, and bacilli ; by the alkaline salts formed 
through the frequent (normal and abnormal) prevalence of 
acids in the upper part of the intestinal tract ; by the direct 
influence of purgatives, occasionally by even the very smallest 
doses of arsenic and mercurials, though, indeed, the latter are 
tolerated very much better by the very young than by the adult ; 
and by exposures to cold. It is also liable to suffer long from 
the results of typhoid fever, dysentery, and occasionally from 
severe attacks of malaria. 

Disturbances of the circulation depending upon -diseases of 
the liver, lungs, or heart, predispose to passive hyperemia of 
the intestine and diarrhoea. Indeed, when it does occur under 
these .conditions, it is an ominous symptom. In no case of 
intestinal disease the diagnosis ought to be considered complete 
or the prognosis ventured upon, unless the liver, and particu- 
larly heart and lungs, have been examined with great care. 

The variety of causes suggest a number of different treat- 
ments. Disorders of circulation must be regulated while the 
local disease is attended to ; ulcerations of the intestines are to 
be treated on some such method as has been suggested in a 
previous essay on dysentery ; the skin must be kept cool by 
bathing or sponging; the air-supply cool and plentiful. 

Most cases of intestinal catarrh (with or without gastric 
catarrh) and diarrhoea depend on the presence of improper food 
and the derangement produced by it. It ought to be removed 
as speedily as possible. When the process of fermentation is 
still limited to, or going on in, the stomach, or the stomach 
still contains injurious masses, these ought to be brought up. 
In such a case the sound judgment of the practitioner has to 
decide whether emesis is still useful, or whether the stomach 
ought to be irrigated and washed out. Most cases of " gastro- 
enteritis" are pre-eminently enteritis ; therefore the claim that 
the washing out of the stomach must not only take place in 
every case, but is the almost infallible remedy in the very worst 



250 THERAPEUTICS OF INFANCY AND CEIILDHOOD. 

class of cases, will have no other result but that of discrediting 
that useful procedure in the eyes of those who are inclined to 
believe implicitly in the value of "new" methods and the 
pretentious claims of short-sighted enthusiasts. If we were to 
believe some of the loud talk of the journals, and the reporters' 
columns in the secular press, gastro-intestinal catarrh would 
soon be " one of the lost arts." 

In fact, the injurious element is in most cases beyond the 
reach of the stomach-pump ; indeed, the latter cannot remove 
anything but what is dissolved or suspended ; the expulsion 
of large masses, curd particularly, through an elastic catheter 
is out of the question. 

The role played by bacteria in the stomach and intestines is 
probably great, but it is surely exaggerated, for the class of 
the schizornycetse is numerously represented alike in the 
healthy and diseased intestine. Even within from four to 
eighteen hours after birth there are large numbers of bacteria, 
cocci, bacillus subtilis, and bacterium coli commune (Escherich) 
in the remnants of digested milk; the latter in the large in- 
testine. How many are introduced into the stomach immedi- 
ately after birth, by the newly-born swallowing air, cannot be 
determined. Besides those enumerated above, there is the bac- 
terium lactis aerogenes which is credited with the decomposi- 
tion of milk-sugar into lactic acid, carbonic acid, and hydrogen, 
thus giving rise to the gases constantly present within the 
intestinal tract. 

The presence of immense quantities of micro-organisms 
proves, however, nothing in regard to the etiology of diseases, 
for they are found in the healthy condition as well, as also 
in such morbid conditions in which the cause of death cannot 
be attributed to the presence of parasites or the usual patho- 
logical changes. Thus in arsenical poisoning the intestines 
are swarming with saprophytes. 

The intestine can be emptied by either purgatives or ene- 



DISEASES OF THE DIGESTIVE OEGANS. 251 

mata ; the former act upon the whole length of the intestine, 
the latter upon its lower portion. Castor oil, so common in 
domestic practice, deserves all the credit given to it. It acts 
mildly and speedily. The addition of opium is not wise ; the 
latter may be administered after the former has exhibited # its 
effect ; the action of the oil must not be inhibited by the seda- 
tive. In many cases a single dose of calomel (one-half grain 
to six) answers better, being both a purgative and antifermen- 
tative. 

The surplus acids of the stomach — mostly lactic and 
butyric — must be neutralized. Magnesium and sodium salts 
must not be selected for that purpose, for they add to the 
diarrhoea. Calcium salts, the carbonate or phosphate, are 
preferable because they have no such effect, but the additional 
advantage of forming with the fat acid an insoluble salt which 
acts as a protection to the sore surface. Doses of from one to two 
grains may be given every hour or two. Beside being an anti- 
fermentative in general, bismuth (the subnitrate or carbonate) 
binds sulphide of hydrogen, and thus has a favorable effect in 
doses of from a quarter of a grain to two grains. They may 
be administered with or without the addition of opium. If 
they be given in liquid form, no syrups must be added to cor- 
rect the taste, but rather glycerin, which has the advantage of 
not turning sour. 

To combat the existing fermentation, antifermentatives must 
be given in regular intervals. Calomel, bismuth, alcohol, 
creasote, salicylate of sodium, salol, naphthalin, resorcin, 
bichloride of mercury, and others, have been eulogized. To 
take effect in the intestine it appears that those who are not 
readily soluble in the stomach ought to prove more useful. 
Still, I feel positive that resorcin in doses of from a quarter to 
one-half of a grain in solution, or as a constituent of a powder 
containing bismuth, chalk, or (and) opium, given every two 
hours, has rendered me the most valuable services in a great 



252 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

many cases. Of the two mercurials I prefer calomel by far, in 
doses of from a twentieth to a quarter of a grain every few 
hours. The antifermentative effect of alcohol in the dilution in 
which we are entitled to give it as a stimulant, though the sum 
total of a daily dose may be large now and then, is not great ; 
salicylate of sodium is less effective than any of the rest, crea- 
sote acts more vigorously in the stomach than in the bowels, 
salol and naphthalin are not easily borne by many. 

Opium, by its inhibitory effect on reflexes, diminishes 
hyperesthesia, hyperperistalsis, and hypersecretion. The ob- 
jections to its use in the diarrhceal diseases are theoretical only. 
Doses of from one-tenth to one-third of a grain of Dover's 
powder every two hours, in all sorts of combinations, act very 
well indeed, and may well be considered indispensable, when 
the above indications are to be fulfilled. Its time has arrived 
when the odor of the evacuation begins to be normal ; but it 
finds no contraindication in those cases of " follicular enteritis" 
of a chronic nature which exhibit their tendency to malodorous 
discharges for weeks in succession. 

In acute cases, and when the stomach participates in the pro- 
cess, astringents, such as lead, tannin, gallic acid, alum, etc., 
are badly borne. In chronic protracted cases they will find 
their indication. Nitrate of silver does better in many cases, 
one-fiftieth to one-thirtieth of a grain in two drachms of dis- 
tilled water (dark bottle) every two hours. In chronic cases 
only, coto, from half a minim to a minim of the fluid extract, 
will sometimes act favorably. 

Of the stimulants, alcohol may be admixed to food. Bad 
brandy or whiskey contains fusel oil, which is a paralyzing 
agent. Whiskey is therefore preferable with us, because it can 
be obtained in greater purity for less money. It must not be 
administered unless diluted. Camphor is better borne than am- 
monia. It is easily taken when simply rubbed off with glycerin 
and suspended in mucilage (one-fourth to two grains everyone or 



DISEASES OF THE DIGESTIVE ORGANS. 253 

two hours). The strongest nerve-stimulant of all is Siberian 
musk. Urgent cases of collapse require one to two grains every 
fifteen or thirty minutes (best suspended in mucilage) until six 
or twelve grains have been taken. A very good stimulant in 
collapse is the injection into the bowels, through a long flexible 
tube (catheter No. 12) of hot water with some alcohol, and 
one or a few drops of tincture of opium. In threatening 
cases of heart-failure strong coffee, hot or iced according to 
circumstances, by itself or in mixtures, may be used to advan- 
tage. Cold tea may be tried in small doses, particularly in 
the chronic cases of older children. 

In acute cases of intestinal (or gastro-intestinal) catarrh with 
high temperature, applications of water, of from 60° to 70° 
F., to the abdomen will render good service. The cloth must 
be wrung out thoroughly, covered with rubber cloth and 
flannel, and changed when warm. Anaemic children and 
those with much pain require warm or hot applications, which 
may be preceded by a warm bath. Frequent injections of 
water of 100° and more, with or without an antifermentative, 
such as thymol (1 : 1000 or 2000), answer well in most cases, 
not only in rectal catarrh.* In great debility, or collapse, the 
water ought to be from 105° to 112°, and contain some alcohol 
and opium, or (and) a teaspoonful of the tincture of musk. 
The addition of gum-arabic to the injection, or the use of 
glutinous decoctions (flaxseed) instead of water has a satisfac- 
tory influence. Starch injections have the advantage of adding 
to the nutrition of the body by the facility with which the 
colon changes amylum into dextrin, which will be absorbed. 
Part of the injected water will always be absorbed, fill the 
blood-vessels, and may prevent intercranial and other throm- 
boses. Indeed, in many bad cases in which the cerebral 
symptoms of the so-called hydrencephaloid condition have 

* A. E. P. Davis in The Medical News of July 6, 1889. 



254 THEEAPEUTICS OF INFANCY AND CHILDHOOD. 

made their appearance, or are imminent, frequent injections 
into the rectum of a few ounces of warm fluid contribute con- 
siderably to the restoration of circulation. 

In hot weather doors and windows must be kept open, the 
coolest place selected in the house or neighborhood, day or 
night ; for night air is preferable to no, or foul, air, sea air or 
country air, particularly at some altitude, to the city. When 
the weather is hot and the body warm, it must be washed with 
cold or cool water, or water and alcohol (5 : 1), frequently. 
Cold feet must be kept warm. 

The food-supply must depend on the condition of the 
stomach and the upper part of the intestine, and also on the 
rapidity of the peristaltic action of the latter. The complica- 
tion of gastritis with enteritis contraindicates the introduction 
of food altogether. Abstinence is better in cases of intense 
vomiting than the use of ice ; the latter may quiet the stomach 
for a while, feel pleasant, but it fills the stomach which ought 
to remain in absolute rest, and excites peristalsis. As I said 
in a previous paper, babies tolerate abstinence better than 
ingesta on an irritated stomach. Beef-tea ought to be avoided ; 
its concentration of salts is irritating. If in convalescence it be 
given at all, it must be mixed largely with barley-water or 
rice-water. 

In all cases of "summer" diarrhoea milk must be avoided. 
Bad cases forbid raw milk, boiled milk, milk in any and 
every shape, for days and longer. Its rapid transformation 
and fermentation contraindicate even the smallest quantities, 
also its presence in farinaceous mixtures. The absence of 
gastric juice (pepsin and hydrochloric acid) in the stomach of 
a feverish child or one that is being drained of its fluids pre- 
vents the digestion of albuminoids. Even mother's milk is 
often not borne to any extent. When milk is again tried 
after a while, it ought to be done very carefully ; cow's milk 
thoroughly boiled, or sterilized with six times its volume of 



DISEASES OF THE DIGESTIVE ORGANS. 255 

barley-water at first, the percentage of milk to be increased 
slowly. We must not forget that cow's milk, ever so often 
boiled or sterilized, is still cow's milk. Milk may be re- 
placed by the white of egg, which must be thoroughly mixed 
with barley-water, and some salt added, and as much sugar as 
is required to make the mixture palatable. During the course 
of a day and night the whites of from one to five eggs may 
be given according to the case and age. Severe vomiting and 
diarrhoea demand, as suggested, total abstinence for from two 
to eight hours or more. 

Afterwards, mucilaginous or farinaceous decoctions may be 
given in small doses at short intervals. A mixture which has 
rendered me very valuable services is about as follows : Five 
ounces of barley-water, the white of one egg, from one to 
two teaspoonfuls of brandy or whiskey, some salt and sugar ; a 
teaspoonful every five, ten, or fifteen minutes according to cir- 
cumstances. Mutton broth may be added to the above mix- 
ture, or it may be given by itself, with the white of egg and 
some salt. 

The tumefaction of the mesenteric glands is of frequent occur- 
rence. Its results are very serious, though the non-absorption 
of chyle does not depend exclusively on the functional incom- 
petency of the glands. The latter has often been taken to be 
identical with the symptoms comprised under the name of 
tabes mesenterica, an error which I shall discuss in the second 
volume of Keating's " Cyclopaedia." There it will be shown 
that the symptoms called by that name, and leading to emacia- 
tion and marasmus, are more frequently dependent on chronic 
peritonitis — mostly of tubercular nature — than on simple in- 
flammatory hyperplasia of the glands. The latter can be more 
safely prevented than cured. Its original cause is mostly a 
simple diarrhoea. The irritation of a mucous membrane 
always leads to that of the neighboring glands ; the glands 
near a nasal catarrh, a stomatitis, a diphtheritic process, a 



256 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

pulmonary catarrh, produce secondary adenitis. Thus the 
mesenteric glands near an intestinal catarrh are soon con- 
gested, and begin to swell. Cell-proliferation accompanies the 
changed circulation ; when its original cause — viz., the hy- 
peremia of the mucous membrane — has ceased, absorption of 
the newly-deposited material will always take place in the 
same way that the swelled glands of the neck will disappear 
when a nasal catarrh is treated with cleansing and disinfecting 
injections. As soon, however, as the newly-formed cells have 
been transformed into firm fibrous tissue, the possibility of 
absorption becomes less from day to day. Thus, the prevention 
of mesenteric glandular hyperplasia consists in the immediate 
removal of a diarrhoea. Be it ever so mild, it is always a mor- 
bid process. Be its name ever so innocent (for instance, 
" dental"), and the prejudice in favor of letting it alone ever 
so strong, it leads to anatomical changes in the mucous mem- 
brane and the glands which may become permanent. When 
a diarrhoea has been protracted, it may safely be assumed that 
the glands have undergone chronic changes. Then the cau- 
tious administration of an iodide, preferably sodium, is in- 
dicated, in daily doses of from five to fifteen grains, according 
to the age of the patient, the severity of the case, and the 
probable duration of the process. It must be continued for 
weeks, and then may be replaced by three daily doses of 
from five to twelve minims of the syrup of the iodide of 
iron. 

Primary tuberculization of the mesenteric glands is quite 
rare ; so is primary tuberculosis of the intestine, in spite of the 
fact that meat and milk containing the bacillus are known to 
be the occasional cause of tuberculosis of the bowels. Both 
are, as a rule, the results, or complications, of general tuber- 
culosis, and in this way they, and tubercular peritonitis, are 
not uncommon. Thus, the treatment of tubercular tumefac- 
tion of the mesenteric glands forms part of the measures 



DISEASES OF THE DIGESTIVE ORGANS. 257 

undertaken for the relief of the symptoms of the general in- 
fection, and leaves but little to hope. Still, there are cases in 
which the tubercular nature of the swelling cannot be doubted, 
that still are liable to get well. There are now on record a 
number of cases of peritoneal tuberculosis in which lapa- 
rotomy was performed, either through a mistaken diagnosis or 
purposely, with relief for the symptoms, and apparent re- 
covery. Indeed, there can be no doubt that a number of 
cases of peritoneal tuberculosis, in which the diagnosis was 
hardly doubtful, improved considerably, either under no treat- 
ment at all, or under measures calculated to benefit the gen- 
eral tubercular condition. Thus, even such cases permit of a 
hesitation to pronounce a fatal prognosis. 

The conditions alluded to must not be mistaken for tume- 
faction of the mesenteric glands from other causes (for in- 
stance, primary lymphoma, the glandular enlargement of 
leucocythsemia or syphilis, or sarcoma which occurs primarily, 
or from carcinoma which is met with secondarily in. young or 
older children). Lymphoma and sarcoma are positively im- 
proved by the protracted use of arsenic, in increasing doses, 
such as are discussed in a previous paper. Syphilitic swellings 
require the persistent administration of active doses of both 
mercurials and iodides. 

In perityphlitis, which is a very frequent disease in childhood, 
absolute rest is required. The patient must use the bed-pan 
and urinal, and must not be permitted under any circum- 
stances to change his position without being aided. The dis- 
turbance of an incipient peritonitis by mechanical causes is a 
serious matter ; recent adhesions are very liable to be torn and 
give rise to new attacks. No purgatives must be given ex- 
cept a dose of oil in those rare cases where no evacuation has 
taken place for some time, and the accumulation in the colon 
of large quantities of faeces is considered probable. In these 
cases, however, a large enema of soap and water will mostly 

17 



258 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

fulfil all the indications. Thus, I am not prepared to advise, 
with a few modern authors, the universal treatment of peri- 
typhlitis (and peritonitis in general) with the sulphate of 
magnesium, or a large dose of calomel. The injection, how- 
ever, first of a few ounces of olive oil, and afterwards of large 
quantities of soap and water, through a fountain syringe, is 
indicated after a week or ten days. Opium must be given 
freely by the mouth, rectum, or subcutaneously, in full doses. 
In almost every case ice applications must be made for days 
to the right hypochondrium. The food must be liquid, and 
given in small quantities at a time. The patient must remain 
in a recumbent posture for weeks after apparent recovery, 
and be kept quiet even then, for an abscess may be capsulated 
and perforation may occur. 

When the diagnosis is undoubted and the presence of pus 
can be safely inferred, there is no objection to an aseptic punct- 
ure, which may be repeated a number of times for the pur- 
pose of ascertaining whether there is pus or not. Sometimes 
there is but a small quantity of pus, which may not be easy to 
discover, but requires an operation. The indications for the 
performance of the latter are not easily found in many cases. 
Indeed, the opinions vary with the very best authors — a great 
many of whom have given the very closest attention and the 
very best thought to the subject — as to the best time in which 
the operation ought to be resorted to. Some recommend and 
practise the operation as soon as perforation of the vermiform 
process has taken place, some favor procrastination until the 
beginning of the second week. Besides, there are those who 
object to any operation when universal peritonitis has set in, and 
those who perform laparotomy in the very same class of cases. 
In a number of instances the time of the operation depends 
on the condition of the patient ; immediately after the perfora- 
tion of the gut collapse is sometimes so great as to render the 
operation absolutely inadvisable. In these ice, opium, and 






DISEASES OF THE DIGESTIVE ORGANS. 259 

stimulants are required to bridge over the imminent danger 
until the operation can be safely performed. I have seen such 
cases in which it was considered positively fatal at first, and 
proved successful a week afterwards. There is no class of 
cases in which the responsibility of the medical man is greater, 
and great knowledge and keen judgment are more urgently 
demanded. Not every case terminates in suppuration. In 
some there is a great deal of inflammatory exudation. In 
them the protracted use of the iodide of potassium or sodium, 
lanolin ointments of the same, and occasional vesicatories will 
render good services. I have known many who had repeated 
attacks extending over years, and finally got practically well, 
not having anything to complain of for long periods. 

After recovery, purgatives must not be given for a long 
time; but, as a matter of precaution, warm enemata must be 
administered every day. 

As there is a difference between peri- and para-metritis, so 
there are cases of para-typhlitis to be distinguished from peri- 
typhlitis. In these cases, local inflammation, exudation, and 
suppuration have nothing to do with the vermiform process. 
Para-typhlitis consists in an inflammation and suppuration in 
the copious connective tissue between the pelvis and the colon, 
which at that place is not covered by peritoneum. 

Such abscesses are the result of trauma sometimes ; not in- 
frequently of pelvic abscess; inflammation of the psoas; 
caries of the vertebrae; sometimes no cause can be found. 
They will develop rapidly and become very large. The ab- 
scesses are so large that sometimes pints or quarts of pus will 
either be discharged spontaneously or be removed by incision. 
But suppuration will not always result from this inflammatory 
process in the connective tissue, but inflammatory exudation 
only. When this happens, the treatment consists in the internal 
use of the iodides, and the applications of ointments of iodo- 
form or iodide and lanolin, or of iodoform collodion (1 : 8-10) 



260 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

several times daily ; cold-water applications which are kept up 
until they become warmed ; or sometimes warm poultices, par- 
ticularly in the cases of very ansemic children, will be found 
to be pleasant and useful. 

Twenty-five per cent, of all the cases of invagination or 
intussusception of the bowels occur in the first year of life 
(two-thirds of them between the fourth and sixth month), and 
fifty-three before the end of the first year.* Thus, a knowl- 
edge both of the condition and the means to remedy it are 
essential to every person who has many children intrusted to 
him. The only successful treatment consists in the reposition 
of the intestine. When it has been accomplished the relief of 
all the symptoms is immediate. The anxious expression, pal- 
lor, and collapse improve instantly, the little patient goes to 
sleep, and soon takes food. In the commencement of my 
practice, when the invagination extended down to the rectum 
I employed large stomach -sounds for the purpose of reducing 
the invaginated mass, but I have almost invariably found the 
case to be worse afterwards, because the sound will crowd the 
parts upon each other. I also used to blow air into the intes- 
tine by means of bellows through a long tube ; and in order to 
make the supply more regular I availed myself, twenty-five 
or thirty years ago, of an apparatus for the production of car- 
bonic-acid gas. After that time, when the siphons containing 
carbonic acid and mineral waters were invented, I used them 
for the purpose of filling the intestine more or less slowly with 
both gas and water. All these measures have proved success- 
ful in occasional cases. What has rendered me better service, 
however, is the following simple plan : The baby is turned on 
its belly, the hips are raised, the abdomen gently supported 
by a soft pillow. The mouth and nose, being the lowest part 
of the body, must be protected. The baby is then ansesthet- 

*See my " Intestinal Diseases," p. 242. 






DISEASES OF THE DIGESTIVE OKGANS. 261 

ized with chloroform, and warm water is poured into the 
rectum with but little pressure. The injection is frequently 
intermitted, while the anus is closed by the finger. At the 
same time the abdomen, in the direction from below upward, 
is gently kneaded and its contents moved about. 

In not a few cases have I seen immediate result from this 
treatment in the course of the last twenty years. When re- 
duction has been completed, the baby must be kept absolutely 
quiet, take opium, now and then a rectal injection of chloral 
in solution, and wear an abdominal bandage just tight enough 
to steady the bowels. 

In adults, Kussmaul reports favorable results from washing 
out the stomach. When the simple measure which I propose 
is unsuccessful, after a number of trials, laparotomy ought to 
be performed. The successful cases of laparotomy are not 
very numerous, but sufficiently so to justify the operation as 
the only means that promises a favorable result in irreducible 
cases. The late Henry B. Sands saved a baby of six months 
by this operation, and there are other similar cases on record. 
It is necessary to operate in time, and not delay too long; 
for, at the best, laparotomy, in these cases, has its serious 
difficulties. 

At an early period all the tissues involved are hypersemic 
and soft, with a tendency towards gangrene. In a child of 
eight weeks, on whom I operated, it took me ten minutes to 
separate the parts from each other, although I had the invagi- 
nation, measuring six or seven inches, outside of the abdominal 
cavity. This delay was due to the softness of the tissues, the 
close impaction of the three layers, and the presence of a large 
amount of mesentery in the mass. Besides, the field of opera- 
tion is very small and the difficulty of returning the intestine 
into the abdominal cavity very great indeed. 

The medicines available for dislodging intestinal worms are 
all strongly irritant. They must not be given unless the 



262 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

diagnosis has been made positive. It is better that the diag- 
nosis of a gastritis, enteritis, or meningitis, when present, 
should be made by the medical man than that the child should 
be punished for his carelessness. Before taking anything to 
expel taenia, a child ought to be in fair general condition. 
Moreover, its own taenia, the mediocanellata, is the most diffi- 
cult to expel. The best time is when proglottides are seen in 
the movements. Moderate abstinence for days, and a purga- 
tive (castor oil), ought to precede the administration of drugs. 
The parasite must be expelled ; for though the symptoms may 
not be urgent, some day there will come either local or re- 
flected ones. 

Spontaneous emigration will be noticed occasionally, but it 
is rare and not to be expected. After the successful termina- 
tion of the cure the intestine must be allowed rest. The 
plainest diet, such as milk, and strained farinacea, and peptones, 
are indicated for days. 

I have administered a great deal of kamala, sometimes ten 
to fifteen grammes (a quarter to one-half of an ounce), during one 
hour, early in the morning ; the breakfast (milk) to be post- 
poned for two hours. The effect was not uniform, and often 
negative. It was improved by giving a dose of twenty-five 
centigrammes to one-half gramme (four to eight grains) four 
or five times daily, for ten days or more, previous to the larger 
dose. A few hours after the larger dose castor oil ought to be 
given. 

Kousso, four to fifteen grammes within two hours, after the 
required preparation, to a child of from two to ten years. 

Extract of filix mas has proved most successful in my hands. 
A small child may take one gramme (fifteen grains) in an 
aromatic mixture within one early morning hour. A drachm 
is tolerated and required by a child of seven or eight years. 

Pelletierin tannate is given in doses of one or three deci- 
grammes (0.1-0.3 = grs. iss to v). I have but little experience 



DISEASES OF THE DIGESTIVE ORGANS. 263 

with it. It is obtained from cortex punicse granatum, which 
was (and is still) given as a decoction, but is too disagreeable 
and sometimes dangerous a mess for a child or infant. 

For the removal of ascaris the general preliminary treat- 
ment ought to take place ; at least, the bowels ought to be 
moved gently. The powdered semina cinse, or flores cinse, one 
gramme or more, mixed with a syrup, and followed by castor 
oil, will work well. Santonin, which is obtained from it, 
works as well and more pleasantly. From one to six centi- 
grammes (gr. J— J-i) several times a day, with a purgative 
such as magnesia, calomel, or jalap. The latter addition is 
desirable, inasmuch as now and then poisonous symptoms may 
appear. Older children will complain of "xanthopsia," yel- 
low vision. Urine and conjunctiva are yellow, sometimes. 

As oxyuris vermicularis is frequently found in the rectum, 
or its neighborhood, the internal administration of drugs is not 
indicated. The external results, such as vaginal catarrh, must 
be treated locally. The worm is removed by a small piece of 
blue ointment introduced into the rectum, or rectal injections 
of vinegar and water (1 : 3-4), corrosive sublimate (1 : 1500- 
6000), or decoctions of onions or garlic. It is difficult to dis- 
lodge, as it also inhabits the colon and even the small intestine. 

Anchylostoma duodenale has attracted a great deal of atten- 
tion of late, and may become of more practical importance to 
us when the blessing of immigration from the parts where the 
worm is indigenous will go on as hitherto. 

The male is from six to ten, the female from ten to eighteen, 
millimetres in length (J-J inch). The mouth is bell-shaped ; 
there are two dental prominences above and four below. Par- 
ticularly the female is thus characteristically endowed, so that 
it sucks and bites at the same time. Eggs are found in the 
faeces. They are smaller than those of ascaris. It was found 
in large numbers among the Italian workmen of the St. 
Gothard tunnel, the tile laborers of the Rhenish provinces, 



264 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

and the Hungarian miners and their children. The cause of 
its presence is looked for in the muddy water they drink, which 
is filled with the ova, and the clay they work in, which contains 
the larvae. The general symptoms are very severe and dan- 
gerous, — debility, paleness, utter exhaustion as in pernicious 
anaemia, relative diminution of red blood-cells. This "Egyptian 
chlorosis" was explained by Griesinger by the presence of 
anchylostoma, as early as 1854. Besides, there is pain in the 
epigastrium, constipation, mucus and bloody discharges, some- 
times real hemorrhages and dyspnoea. 

Anchylostoma duodenale requires santonin, thymol (adults 
took two to ten grammes daily), and principally extract of 
filix mas. 

Umbilical hernia is of very frequent occurrence, but seldom 
attended with danger. Incarceration takes place very rarely ; 
still, Treves and others have reported successful operations 
for such accidents. As there is a predisposition to the devel- 
opment of this variety of hernia, so there is a tendency towards 
spontaneous recovery. The round umbilical aperture will 
normally change after a number of months, or even a year, 
into a narrow fissure, more fat will develop, the muscles will 
become stronger, and then the intestine will be retained within 
the abdominal cavity. To accomplish this still more certainly, 
it is desirable to retain the contents of the hernial sac inside 
the abdomen. For this purpose, trusses are very unavailing. 
Strips of adhesive plaster will serve very much better, but in 
most cases they are objectionable because they irritate the sen- 
sitive skin of the baby. 

Whatever application is made to the hernia directly must 
be larger than the aperture. It should not be too hard. 
Linen compresses, and those of woven lint, plates of cork 
covered with linen or lint, may be applied and held in position 
by means of a bandage. Knitted bandages will suit better 
than the ordinary bandage of linen, cotton, or flannel. 



DISEASES OF THE DIGESTIVE OKGANS. 265 

Inguinal hernia in the newly-born or the very young is apt 
to recover spontaneously. When the short and straight in- 
guinal canal becomes longer and more oblique, in the course 
of a few years, and the amount of fat goes on increasing, the 
rupture may disappear ; but all these predisposing factors 
never succeeded in effecting a cure by themselves. This 
was accomplished only when the hernia was retained inside 
the abdominal cavity completely and constantly, by means of 
a truss, which must be worn for years. It must not be re- 
moved except when the baby is sleeping quietly. Trusses are 
uncomfortable in the beginning, and give rise to cutaneous 
irritation, particularly under the influence of urine. So much 
the more is it necessary to keep the truss clean, and always 
to select one which fits exactly without exerting too much 
pressure. 

Hernia is easily reduced into the abdominal cavity. But 
there are on record quite a number of cases in which incar- 
ceration and strangulation required operative interference. 
The operation should not be delayed after reduction proved 
impossible, even under the influence of an anaesthetic. An 
instance of a successful operation on a case of strangulated 
femoral hernia, which occurred in a girl of eleven years, has 
been reported by St. Germain. Rees succeeded in reducing 
an inguinal hernia by aspirating from the intestine a quantity 
of turbid liquid. An exceptional case of the kind, however, 
must not be recommended for general adoption. 

Catarrh of the rectum behaves very often like a merely local 
disease. Indeed, it may occur as the result of a local irritation 
of the anus (scratching, sitting on muddy stoops) and oxyuris, 
foreign bodies, or hardened fseces. In all these cases the 
treatment has to be directed to the cause, which must be re- 
moved. Warm injections of water, flaxseed tea, starch decoc- 
tion (with a little opium in tenesmus) are ample. Real proc- 
titis, leading to ulceration (other than dysenteric) or fibrous 



266 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

hyperplasia, will be but infrequent results. But it may occur, 
the infiltration may become copious and lead to an invasion of 
the surrounding cellular tissue. This periproctitis gives rise 
to abscesses, and often to fistula, either external or internal, 
complete or incomplete. These, as well as the periproctitic 
abscesses, due to pyaemia, sepsis, or the severe form of typhoid 
fever, require early incision. 

Prolapse of the anus and rectum is the consequence of ca- 
tarrhal and inflammatory irritation and softening. It will fol- 
low chronic catarrh and dysentery. It is produced by debility 
of the sphincter, which is often congenital, sometimes the 
result of neighboring diseases ; also due to drastic purgatives, 
or constipation with the incidental straining. Such straining, 
resulting in prolapsus, is also produced by the presence of 
polypus or worms in the rectum, by stone and catarrh of the 
bladder, and phimosis. A predisposition arises from the 
peculiar shape of the rectum in the young. It is straighter, 
inasmuch as the sacrum is not scooped out as it is in the 
adult. 

The temporary reduction of the prolapse is readily accom- 
plished, particularly in such cases as those in which the 
sphincter is feeble, but the intestine will come down again. 
Attention must be paid to defecation. The children must 
not be allowed to strain. Thus the chamber must be placed 
in such a position, and raised to such an extent, that the feet 
cannot touch the floor, or the child must not be permitted to 
sit up during defecation. 

Hippocrates makes the following remark on this subject: 
"In children suffering from stone, and protracted genuine 
dysentery, the rectum is apt to protrude. It should be 
pressed in with a soft sponge, and touched with a snail. Then 
the patient should have his hands tied, and be suspended a 
short time, and thus the rectum will slip in. If it comes down 
again, a band should be placed around the loins ; a bandage 



DISEASES OF THE DIGESTIVE ORGANS. 267 

must be attached to this, and the rectum, after being moistened 
with a decoction of lotos, be replaced with a soft sponge. 
Also, the intestine must be washed with this decoction and the 
bandage carried up between the legs to the umbilicus. During 
defecation the baby must sit with extended legs upon the feet 
of the mother, its body leaning against her knees." 

Many appliances have been devised to retain the rectum 
inside. Adhesive plaster has been used as best it could, and 
a number of instruments have been invented for the purpose 
of retaining the rectum in position, while leaving an opening 
for the passage of the faeces. They have been made of hard 
rubber, lead, and other materials. 

Others have used a tampon, and some a compress to hold 
the nates together ; but a tampon will certainly dilate the par- 
alyzed sphincter more than it was before. 

Curling confines his efforts to compressing the nates. 

The main attention must be given to the treatment of con- 
stipation or diarrhoea, of the local catarrh, the rectal worms, 
the presence of polypi, the presence of stone in the bladder 
and phimosis, and all the causes of straining and prolapse 
which have been enumerated above. 

But there are direct indications which can be fulfilled. As- 
tringents have been used locally in the form of injections ; 
principally alum and tannin, in solutions of one or two per 
cent. Ice has been applied locally, and injections of from 
half an ounce to an ounce of ice-water can be used with advan- 
tage three or four times a day. 

One enema must be given daily for the purpose of empty- 
ing the colon and avoiding the possible straining. 

In most cases there is considerable swelling, sometimes real 
hypertrophy of the mucous membrane and of all the tissues. 
Swelling and hypertrophy must be reduced. A part of the 
hypertrophied tissues has been excised. Caustics have been 
used, for instance nitrate of silver. It must be carefully neu- 



268 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

tralized immediately after the application by chloride of sodium 
in solution. Concentrated nitric acid has been employed for the 
purpose of destroying some of the superfluous tissue. The 
best remedy, however, for this purpose is the actual cautery. 
It should be applied either in long welts or stripes, or at half 
a dozen or a dozen points. It matters not whether the gal- 
vano-cautery, or Paquelin's thermo-cautery, or the common 
actual cautery is selected. 

For the purpose of strengthening the sphincter, I have used 
frequently, for dozens of years, an ointment consisting of ex- 
tract of nux vomica, one part, in ten or fifteen parts of fat, to 
be applied to the lower part of the rectum from three to five 
times a day, or every time the bowel protrudes. The internal 
administration of strychnia is of very little avail ; but that of 
ergot is serviceable. The subcutaneous injection of strychnia 
(sulphate one-sixtieth to one-thirtieth grain dissolved in 
water, once daily) in the neighborhood of the sphincter will 
be beneficial, particularly when supported by the action of the 
interrupted electric current, which may be applied for a few 
minutes once or twice every day. 

Fissure of the anus is by no means rare in infants and 
children, particularly in the latter. It gives rise to symptoms 
similar to those encountered in adults : severe pain during de- 
fecation, tenesmus, dysuria. Many cases of alleged flatulency 
and colic, and excruciating screaming spells, are due to fissure. 
The more severe form follows a direct injury by foreign bodies, 
hard faeces, etc.; a mild form is due to slight erosions and 
ulcerations, the rhagades of congenital or acquired syphilis, or 
the sores made by erythema, eczema, or herpes, and by vulvo- 
vaginitis. The mildest form is that which is found on a very 
loose and dilatable anus. This yields readily to a mild treat- 
ment of the sore with a solution of nitrate of silver. Cases 
depending on syphilis require both a general and local treat- 
ment, vaginal catarrh must be stopped, and eczema healed. 



DISEASES OF THE DIGESTIVE ORGANS. 269 

The treatment of the severe form has consisted in the relief 
of occasional diarrhoea, and that of the more frequent consti- 
pation by enemata and mild purgatives, in the application of 
astringents, such as lead, copper, zinc, or alum ; or of caustics, 
such as nitrate of silver (Esmarch) or of nitric acid. This 
treatment is painful and tedious. Boyer advised incision 
through the whole of the sphincters. The open wound may 
bleed and give rise to ulceration, or sepsis. The proper treat- 
ment consists in dilatation of the sphincters. Josseline directs 
it to be gradual, thereby protracting uncertainty and pain. The 
best and speediest method, however, is forcible and instanta- 
neous dilatation, without anaesthesia. The operation takes so 
little time that it is hardly required except in very puny or 
convulsive infants or children. The introduction of two fin- 
gers of the same hand is rarely sufficient ; three or four do 
better. The easiest way is to use the two index fingers; a 
sufficient dilatation is recognized by the distinct sensation that 
the muscular fibres have given way. The external wound is 
trifling and but superficial. 

In the rare cases of fissure and polypus combined the treat- 
ment has to be directed to both. 

Polypi of the rectum are tumors of the size of a pea up to 
that of a cherry or hazel-nut, or more. They are single or 
numerous, quite soft, or more frequently of greater consistency, 
composed mostly of cells or cellular tissue, quite vascular, and 
contain often a harder adenomatous nucleus and a Lieberkuhn 
gland imbedded in them. They are either pedunculated or 
sessile, on a broad base. They are sometimes found between 
the two sphincters, mostly above and near the inner sphincter ; 
not infrequently, however, all over the middle portion of the 
rectum, and sometimes quite near the so-called third sphincter. 

Among the symptoms we meet with abnormal defecation 
(constipation, diarrhoea, or both in alternation), sometimes 
enteralgia or tenesmus, and frequently a discharge of mucus 



270 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

or blood. Tenesmus is found about polypi when seated near 
the internal sphincter, or between the two sphincters. Blood 
is seldom mixed with mucus, mostly quite clear, from half a 
teaspoonful to a teaspoonful, sometimes more, so that the con- 
stant repetition of these small hemorrhages is sufficient to 
result in anaemia. The tumor is often pushed into or through 
the anus during the evacuation of the bowels. 

The treatment consists in the removal of the tumor by 
means of the snare, the galvano-caustic snare, by pincers, or by 
the fingers, or by ligature. The latter is easy of application 
in all cases in which every movement of the bowels succeeds in 
rolling out the growth like a foreign body. In these many ex- 
cursions a polypus with a thin pedicle is often removed spon- 
taneously. When that occurs there is hardly a show of blood. 
Indeed, there is seldom much bleeding after removal. It is 
true that some writers report the occurrence of hemorrhages, 
but in infants and children, with whom varicosities of the 
blood-vessels are exceedingly rare, I have never seen a hemor- 
rhage of any account after breaking the pedicle with my 
finger in the rectum. The latter is very accessible indeed 
to an index-finger of moderate size. 

Sessile polypi do not give rise to urgent symptoms, and are 
not easy to find, sometimes. The astringent injections which 
are to remove them must be mild. Solutions of one per cent, of 
alum, injected several times daily, will be found sufficient, or 
a two-per-cent. ointment, or suppository. 

The diagnoses of diseases of the liver are more numerous 
than its diseases. Primary affections are rare. Enlargement is 
frequently assumed to exist when the size is normal. In the 
foetus and infant the liver is proportionately large, but appears 
still more so because of its lower part not being covered by the 
ribs (which in the young are more horizontally placed) as it is 
in the adult. Besides, the tympanitic intestines encroaching 
upon the liver from below and behind, and the rhachitical con- 



DISEASES OF THE DIGESTIVE ORGANS. 271 

traction of the chest- wall, render a much larger surface of the 
organ accessible to percussion and palpation. Thus, actual 
and primary enlargement is not a common occurrence. Sec- 
ondary enlargement, however, may depend on constitutional — 
either chronic or acute — disorders, such as alcoholism, syphilis, 
leucocythsemia, chronic tuberculosis, suppuration of bones or 
glands, malaria, or typhoid fever. The therapeutics of these 
kinds of enlargement depend, therefore, on the character of the 
different causes. 

Another series of enlargements is that which results from 
changes in the circulation. Diaphragmatic pleurisy call con- 
strict the vena cava inferior and thereby lead to hypertrophy 
of the liver, ascites, and death. Pneumonia in its acute stage 
impedes the hepatic circulation, temporarily mostly; when it 
is chronic, the consecutive hypersemia may lead up to hyper- 
trophy ; the same effect may be produced by the persistence of 
pleural effusions on either side. More frequent yet is the sec- 
ondary hepatic enlargement of heart-disease, not so much in 
the congenital form, in which the amount of blood is greatly 
reduced by the low state of general nutrition, as in acquired 
(mostly rheumatic) endocarditis. The number of such cases 
increases with every year of life ; indeed, children of eight or 
ten years, with chronic valvular diseases and consecutive en- 
largement of the liver, are subjects of frequent observation. 
Thus, indeed, the treatment of the hepatic disorders is rather 
that of the primary disease than of the secondary hepatic changes. 

Fatty infiltration of the liver is, in the very young, not 
often complicated with much increase in size. For, indeed, to 
a certain extent it is normal. But, in ill nutrition, protracted 
diarrhoea, chronic phthisis, and after severe cases of diph- 
theria or scarlatina, an actual fatty degeneration is liable to 
occur, with enlargement of the organ. Sometimes it is found 
combined with interstitial inflammation (cirrhosis), particularly 
in cases of syphilis, rhachitis, tuberculosis, or after measles or 



272 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

scarlet fever. All of these facts are here alluded to in order 
to show that the intellectual physician can accomplish a great 
deal by attending to an evil before it is developed. Nothing 
is easier and more luckless than to prescribe iodides, calomel, 
or purgatives for an established local disorder, and fold the 
hands at the sight of an impossibility ; nothing more efficient 
and happy than to watch and treat in time rhachitis and 
measles and scarlatina and the whole army of primary ail- 
ments. Obsta principiis. Noiseless prevention counts more 
than the loud officiousness of the recipe fiend after the evil 
has been permitted to advance to maturity. 

Besides the cirrhotic induration of the liver, complicated 
with fatty infiltration, there are rare instances of genuine cases 
of cirrhosis, mostly connected with, or depending on, alcohol- 
ism, syphilis, and tuberculosis. The atrophic form is rare and 
mostly due to syphilis ; the hypertrophic, with more or less 
jaundice and but a mild degree of splenic enlargement, is more 
frequent. Still, the records of the journals and transactions 
exhibit but seventy cases altogether. Ascites is not so fre- 
quent in the young as it is in the adult; it is more often 
observed as the result of chronic peritonitis than of cirrhosis, 
and of portal obstruction of any kind. The energetic sup- 
pression of the alcoholic habit (more frequently found in chil- 
dren and adolescents than many presume) and the treatment 
of syphilis (not always hereditary) may result in recovery. 
Mercury and iodides are very effective, not only in syphilitic 
cases. In every sort of cases, and in every age, I have suc- 
ceeded in relieving cirrhosis, and sometimes permanently, by 
alternating, by the week or fortnight, the administration of 
iodides (potassium or sodium) and mercury (bichloride or the 
green iodide, and sometimes calomel). 

The therapeutics of congestion of the liver is that of its 
causes, the lungs and heart, phosphorus-poisoning, infectious 
fever, and very high temperatures. While nothing is more 



DISEASES OF THE DIGESTIVE ORGANS. 273 

preposterous than the abuse of antipyretics in the presence of 
moderate temperatures, nothing is indeed more reprehensible 
than to allow paralysis of blood-vessels and even disintegration 
of tissues to take place from excessive pyrexia. The same is 
true of hepatic inflammation and suppuration. In our country 
the former, when general, is mostly traumatic, the latter the 
result of pyaemia, umbilical phlebitis, dysentery, perityphlitis, 
and pleuritis, besides an occasional case produced by pylephle- 
bitis, or ascaris, or a contusion. Many a case of abscess need 
not have occurred if the dysenteric rectum had been disinfected 
by frequent enemata, a perityphlitic or pleural abscess been 
incised in time, and the umbilical phlebitis prevented by keep- 
ing the cord aseptic. Multiple abscesses will always terminate 
fatally ; a single abscess may get well by either aspiration or 
incision and drainage. Of the two I prefer the latter, though, 
indeed, I have seen a successful result from a single aspira- 
tion followed by antiseptic irrigation. 

The treatment of jaundice depends on its causes. The 
dangerous form met with in the septic new-born might be 
prevented, but cannot be cured. That which results from 
syphilitic stricture of the bile-ducts may recover, even after 
months, through a thorough mercurial treatment ; complete 
obliteration of the bile-ducts leaves no hope. The mild form 
depending on the sudden post-natal change in the hepatic 
circulation corrects itself; that which follows a gastric and 
duodenal catarrh in the newly-born, the infant (rarely), or the 
child, will get well with proper diet and medicines, which have 
to be adapted to both individuality and age. As a rule, the 
amount of food ought to be diminished, but little meat (chicken) 
permitted, and milk and farinaceous foods preferred. Alka- 
line waters (Seltzer, Vichy, Waukesha, Poland), bicarbonate 
or phosphate of sodium, bismuth, hydrochloric acid, resorcin, 
calomel will be found appropriate in a great many cases; in 
others, copious cool enemata or tinctura rhei aquosa. Jaundice 

18 



274 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

depending on atmospheric influences has been observed to occur 
epidemically. Such cases require, besides the treatment out- 
lined above, rest in bed, warm bathing, and diaphoretics. 
Jaundice from gall-stones, though it has been observed in the 
very young, even in the newly-born, is excessively rare. The 
rules for both dietetic and medicinal treatment of biliary 
calculi must be the same in all periods of life. Strictly nitrog- 
enous food must be avoided or taken in small quantities only, 
and milk and fruit (oranges, grapes) and fresh vegetables per- 
mitted. Of all the medicinal agents known to me, the sulphate 
and the salicylate of sodium, administered for months in suc- 
cession, have answered best as preventives, to guard against a 
repetition of the attacks. 

Diseases of the spleen are rarely of a primary character; 
most cases of pseudoplasm are congenital, and not amenable 
to any medicinal treatment. The majority of changes occur- 
ring in the spleen are connected with, or dependent on, consti- 
tutional ailments, and result mostly in enlargement of the 
organ. Malaria, leucocythsemia and pseudo-leucocythsernia 
(Hodgkins's disease), and amyloid degeneration have their own 
indications. Rhachitis and syphilis are liable to produce in- 
duration depending on hyperplasia of the connective tissue. 
Tuberculosis of the spleen is a frequent complication in the 
very young, with general tubercular infection. Heart-disease 
may lead to embolism and abscesses (the latter forming also 
a part of general pyaemia), typhoid fever to softening and 
enlargement. This condition expands the peritoneal cover- 
ing and causes perisplenitis, though it be not quite distinctly 
accessible to diagnosis. For indeed the younger the infant, the 
less is percussion — being hampered by the shortness of the chest 
and the frequent occurrence of tympanites — able to reveal the 
exact size of the spleen. Unless it can be felt below the 
margin of the ribs it must not be assumed to be hypertrophied. 
There are even cases in which it can be so felt, and still there 



DISEASES OF THE DIGESTIVE ORGANS. 275 

is no enlargement, for in rare instances the spleen is found 
floating or descended. 

The therapeutics of the constitutional disorders above al- 
luded to has been discussed in previous papers. Quinia, ergot, 
and arsenic have been shown to be efficient in some and abso- 
lutely inert in others. The combination of quinia and ergot, 
with or without iodides, is probably among the most powerful 
remedies in chronic cases. Acute instances of swelling and 
inflammation require ice energetically applied, purgatives, and 
large doses of ergot ; the presence of pus demands incision and 
drainage. To ascertain that condition exploring punctures 
can be made with safety. To what extent extirpation of the 
organ can be rendered serviceable in chronic cases remains for 
the future to demonstrate. Many of them that are dependent 
upon disorder of circulation or nutrition are more amenable 
to a preventive than to a curative treatment. 

Peritonitis, either acute, subacute, or chronic, is a frequent 
disease at any age, and quite common in the young. The 
several forms will interchange and combine or alternate with 
each other; the chronic variety may remain dormant through 
an indefinite period, and suddenly break out with full force. 
All the forms of septic and infectious diseases give rise to it, 
from the sepsis of the newly-born to scarlatina, erysipelas, 
variola, dysentery, and typhoid fever (much more frequently 
without than with perforation). Trauma and perforation from 
any source, straining and contusion, indigestion, diarrhoea, and 
constipation (less frequently in the young than in the adult) 
will lead up to it. Inflammatory processes in the neighbor- 
hood, such as perityphlitis and pleuritis, or simply local irrita- 
tion, as from incipient hernia or retained testicle, are among 
the frequent causes. Perhaps the most frequent origin is that 
from a previous attack which occurred at a period ever so 
distant. After all that has been said in these brief lines, it is 
easy to see to what extent preventive treatment can prove 



276 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

effective. The watching and mitigation of infectious disease 
with a typical course, the speedy disinfection of the intestine 
in typhoid fever and dysentery, the prevention of chronic con- 
stipation or diarrhoea, the proper attendance on perityphlitis 
and pleuritis, the application of a truss and alleviation of the 
difficulties of a strangulated testicle, are just so many safe- 
guards against attacks of peritonitis in individual cases. 

When an acute attack of peritonitis, either local or general, 
has made its appearance, absolute rest is required by both the 
whole body and the affected organs. No unnecessary exertion, 
no motion of the body, no sitting up to evacuate either blad- 
der or bowels, no straining is permissible, no food other than 
liquid, — that is, milk and such farinacea as contain least 
starch, viz., ground barley or oatmeal, preferably the former ; 
for meat requires more pepsin and hydrochloric acid than a 
stomach at a temperature of 104° or 106° is competent to 
furnish, and the system has no worse enemy than half-com- 
pleted or not absorbed peptones. Peristalsis must be stopped, 
for any disturbance of the consolidation of beginning adhesion 
is revenged by the tearing of newly-formed blood-vessels, the 
occurrence of hemorrhages, and the increase of danger. Opi- 
ates must be given by the mouth, rectum, or subcutaneously, 
or by combined methods, in doses sufficiently large not only 
to benumb pain or to procure an occasional sleep, but to obtain 
a condition of constant drowsiness, even sopor, and an effect 
on the pulse. When there is much vomiting, food ought to 
be withheld for half a day or a day. There are cases in 
which even ice pills furnish a new source of gastric irritation ; 
still more frequent is the contraindication to carbonic acid 
gas, which, it is true, gives great relief in some cases either in 
alkaline water or in champagne. In the later stages of the 
disease, when the necessity of feeding becomes urgent, vomit- 
ing may often be avoided by giving, either subcutaneously or 
on the tongue, undiluted, one or a few drops of Magendie's 



DISEASES OF THE DIGESTIVE ORGANS. 277 

solution five minutes before the partaking of food. In the 
first days of acute peritonitis water is a greater necessity than 
food. When it cannot be introduced into the stomach, an 
ounce or two may be thrown into the rectum every hour or 
two hours without annoying it, and without inducing peri- 
stalsis of the intestinal tract. 

Ice-bladders or, if they be too heavy, iced cloths are ap- 
plied to the abdomen to advantage ; particularly when the 
inflammation is still local. When they are objected to, water 
of the usual temperature may be employed first, and the 
latter reduced gradually. Cold must not be employed too 
long in very young or anaemic children ; in these, indeed, 
warm applications are tolerated best. As long as an acute 
peritonitis is still local (pericystitis, perihepatitis), leeches can 
be expected to do good. No purgatives must be given ; in 
children peritonitis caused by constipation is exceedingly rare, 
and the recommendations of magnesium sulphate and other 
strong remedies as given in puerperal and other forms of 
peritonitis — though they may prove justifiable in the adult — 
do not refer to the infant or child. If it be desirable to re- 
lieve the intestinal tract to some extent, the incipient state of 
peritonitis may permit of a tepid enema gently administered, 
with or without the addition of a teaspoonful or half a table- 
spoonful of oil of turpentine added to half a pint or a pint of 
warm water. Rest to the intestinal tract is such an absolute 
indication that the locking up of the bowels for a week or 
ten days becomes a frequent necessity. The tympanites of 
peritonitis is not the result of constipation, but depends on 
the paralytic condition of the muscular layers of the gut, 
brought about mostly by the oedematous effusion into its 
tissue. But when it becomes very annoying, or dangerous 
through pressure upon the diaphragm, some relief may some- 
times be obtained by introducing one or more tubes of 
india-rubber into the intestine. External applications must 



278 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

not be made because of the danger attending renewed peri- 
stalsis. The question whether puncture of the intestine is 
advisable, with a view of allowing gas to escape, cannot be 
answered for every case. Experience has shown that such 
punctures accomplished this purpose, but also that over- 
extension of the intestinal wall destroyed its elasticity and 
prevented the puncture from closing immediately. I have 
seen liquid faeces which had escaped into the abdominal cavity 
through the fine apertures made by the needle of the aspi- 
rator. 

When the case turns out to be one of suppurative peri- 
tonitis, the accumulation of pus may be circumscribed (a local 
abscess) or the whole abdominal cavity is affected. In such 
cases there have occurred occasional perforations into and dis- 
charges through the intestine, ureters, bladder, or umbilicus, 
but it is not windfalls or godsends we have to calculate upon. 
The choice is between an absolutely bad prognosis and the 
incision of the abscess, or laparotomy with proper after-treat- 
ment. The latter operation has also been recommended as a 
curative agent in tubercular peritonitis, and the number of 
reported successes is increasing. While we know that local 
tuberculosis is quite liable to heal spontaneously, we are still 
not justified in attributing the recovery of laparotomized 
tubercular peritonitis to that spontaneity alone, but must 
remember that a good empirical observation is of at least 
as great an objective value as a laboratory experiment made 
under different circumstances, or a microscopical drawing. 

Chronic peritonitis, whether the outcome of an acute attack 
or an independent affection, has its own indications. The 
majority of cases are either traumatic or the results of pre- 
vious diarrhoea, typhoid fever, or tuberculosis. Rest in bed, 
warm bathing, warm poultices offer great relief. Baths con- 
taining iodine, such as St. Catherine's, Kreuznach, and the in- 
ternal administration of iodide of potassium or sodium (of 



DISEASES OF THE DIGESTIVE ORGANS. 279 

iron only when there has been no elevation of temperature for 
some time) will contribute to the absorption of part of the 
exudation, particularly when the latter is very massive. An 
occasional vesicatory will be found opportune. Iodoform may 
be used as an ointment or be applied with collodion (1 : 8-12), 
twice daily, for a long time. Tincture of iodine is less efficient 
and more irritating. Ascites may require paracentesis, but I 
have seen many a case improved by iodides only, in connection 
with other diuretics. Sparteine sulphate (scoparius) is one of 
the best, in daily doses of, altogether, one-half to one grain; 
roob Juniperi, in a number of teaspoonful doses daily, is also 
very effective. Both or either may be combined with the 
iodide. When the solid exudation is obstinate, the blue oint- 
ment may be used in addition to the iodide ; it may be rubbed 
into the inner aspect of the thighs or forearms, particularly the 
former, twice daily; not, however, into the abdominal wall. 
Nothing is easier than to transform a mild chronic form into 
an acute peritonitis by friction and similar traumatism, and 
nothing more certain than that the modern " massage" craze 
has multiplied the cases. On the other hand, there is no better 
means of alleviation and prevention than the rest secured 
to the abdominal organs by the permanent wearing by the 
patients, or those who ever suffered from peritonitis, of a 
bandage easy enough not to annoy, but sufficiently snug to 
hold in position the jumble of formerly diseased and still 
vulnerable intestinal convolutions. 



280 THEKAPEUTICS OF INFANCY AND CHILDHOOD. 

VII. 

DISEASES OF THE GENITOURINARY ORGANS. 

The preventive treatment of the kidneys ought to begin 
with the first hours of the newly-born. After the second day, 
and frequently through a period of some two or three weeks, 
the urine, usually thin and limpid in the infant, is liable to 
eliminate a large amount of uric acid and urates. They are de- 
posited in the pyramids and papillae of the kidneys in orange- 
colored crystals and amorphous powder, and are sometimes 
so copious as to accumulate in the pelvis of the organ and 
also in the bladder. Not infrequently are the cloths of the 
baby discolored by them. The presence of this " urie acid in- 
farctus" is due to the sudden change in the circulation of the 
blood ; it causes an unprecedented elimination of nitrogenous 
material which cannot be kept in solution, and thus removed, 
because the newly-born is not supplied with a sufficient amount 
of water. Its speedy removal is of great importance, for it 
acts as a local irritant, and may give rise to a slight or larger 
renal hemorrhage, to albuminuria (which is a frequent occur- 
rence because of the defective construction of the epithelium of 
the glomeruli), and even to nephritis. Besides, its presence 
in both the kidneys and the bladder is a ready cause of the for- 
mation of renal calculi ; indeed, the vast majority of renal calculi 
and of the centres of vesical calculi consist of uric acid. The 
consideration of these facts conveys at once the conviction of 
the necessity of supplying the newly-born with ample quan- 
tities of water. Much suffering and illness can thus be 
prevented. 

The malformations of the kidneys and its (mostly congeni- 
tal) malignant pseudoplasms furnish but few indications for 
treatment. Abnormal shape and unicity of the kidney (some- 



DISEASES OF THE GENITOURINARY ORGANS. 281 

times amounting to horseshoe kidney), cystic degeneration of 
obstructed uriniferous tubes, carcinoma and sarcoma, are un- 
fortunately not uncommon. Of the latter I collected nearly 
four dozen in my paper on the subject presented to the Eighth 
International Congress. No treatment can be advised but 
that of removal at a time when the growth of the tumor is 
not yet too large. Fortunately, the diagnosis can be made 
with satisfactory certainty, and besides, as a rule, there is but 
one kidney affected. Metastatic deposits in the other kidney 
take place, if at all, at a late period of the development of 
the pseudoplasm. 

Echinococcus and hydronephrosis furnish the usual indica- 
tions to the surgeon. More than one-half of the latter are 
congenital, and therefore unfavorable. The secondary variety 
is caused by congenital hypertrophy of the bladder, pseudo- 
plasms, calculi obstructing a ureter, disease of the prostate 
gland and urethra and its neighborhood. Thus the prognosis 
of the causal treatment is very doubtful in most cases, and a 
direct surgical treatment — aspiration, drainage, and irritant 
injections — is demanded. 

Most cases of floating kidneys in infants and children are 
congenital ; in a few older children, of ten and twelve years, 
symptoms attributable to that anomaly originated in a fall or 
jump from a height. Fortunately, it is a rare occurrence; still, 
I have met with at least eight in the course of thirty-six years. 
I never could advise anything better than a snug and well- 
fitting abdominal bandage. I have not seen a case in which 
I felt justified in advising the removal of the organ. 

Among the symptoms connected with actual or apparent 
renal disease there are two of such importance as to render a 
special consideration advisable, — viz., hematuria and hemo- 
globinuria. The former is always the result of a rupture of 
blood-vessels which may be occasioned by many causes. Cal- 
culus in a kidney or the bladder, nephritis and cystitis, neo- 



282 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

plasms, thrombosis of the renal vein, or an infectious disease, 
such as purpura and cerebro-spinal meningitis, are among the 
principal causes of hsematuria. For the time being we are 
here dealing with that depending on renal hemorrhage only. 
The indications furnished by the presence of infectious dis- 
eases and thrombosis are clear, but the efficacy of the means 
considered appropriate is very doubtful. Stone in the kidneys 
requires flushing the organ with alkali according to the 
method to be soon discussed. The action of ergot, either as a 
fluid or the solid extract, may be tried. If the stomach be 
rebellious the remedy may be administered in the rectum. 
Heart stimulants are often indicated, but it must not be digi- 
talis that is to be selected, because of its local effect on the 
kidneys. Strophantus or sparteine are preferable. Astrin- 
gents, such as are eliminated through the kidneys, lead, tannic 
and gallic acid, will render good service if given in more than 
the doses of the books. The application of ice over the bleed- 
ing kidney is superior to any other remedy, provided the pa- 
tient be not too young; for very small infants do not bear 
the persistent use of ice. 

Nephritis, in the acute, subacute, and chronic forms, is a 
very frequent disease in infancy and childhood. As it is not 
always primary, but quite often a secondary affection, it is 
liable to be overlooked until it is too late. When this ex- 
cessive frequency will be generally recognized fatal results 
will become less, and prevention will be appreciated at its 
full value. The enumeration of the cases of nephritis will 
always be incomplete, but the list of those conditions and 
diseases leading to it comprehends the principal ailments of 
infancy and childhood. First of all, there are the acute in- 
fectious diseases : scarlatina, diphtheria, measles, rubella, 
varicella, malaria, typhoid and cerebro-spinal fevers, amyg- 
dalitis, parotitis, and pyaemia. There are constitutional dis- 
orders, such as syphilis, purpura, and diabetes, also extensive 



DISEASES OF THE GENITOURINARY ORGANS. 283 

eczematous dermatitis, changes in the superficial circulation 
resulting from sudden exposure or the persistent influence of 
a low temperature. Besides, stasis and thrombosis, depend- 
ing on pulmonary and cardiac diseases and diarrhoea, have the 
same result. Irritation of the kidneys by medicinal agents also 
leads up to nephritis ; thus, for instance, chlorate of potassium, 
mineral acids, salicylic, carbolic, and pyrogallic acids, turpen- 
tine, naphthol, styrax, petroleum, tar,* large does of lead, phos- 
phorus, arsenic, mercury, and manganese, — part of which 
are used for internal, part for external medication ; finally, 
irritation of the organ by the uric acid infarctus of the newly- 
born, or by renal calculi, which are by no means rare in the 
very young, gives rise to inflammation. Most of these injuri- 
ous substances exhibit their detrimental effect the more the 
younger the infants; in them a single external application 
of a solution of carbolic acid suffices to produce nephritis. 
The large number of causes of nephritis, as enumerated above, 
if heeded, teaches at least two lessons : first, that the supine 
expectancy in the treatment of infectious diseases is very 
liable to become criminal ; and, secondly, that the effect of 
every irritating remedy, both internal and external, must be 
carefully watched. 

When acute nephritis has been fully established, the first 
indication consists in the procuring of relief for the conges- 
tion of the kidneys. The child must be in bed, the skin 
warm ; a warm bath will fill the cutaneous blood-vessels and 
relieve the internal circulation ; dry cups and hot poultices 
applied to the renal region will have a similar effect. The 

* Balsam of Peru has also been charged with occasioning nephritis. 
Brautigam and Nowack, after having made daily examinations of the 
urines of twenty-two patients, though administering internally fifty-two 
and eight-tenths grammes in eleven days, and in another case eighty 
grammes in twenty-four days, found that it has no such detrimental effect, 
provided it be free of ethereal oils. (Centralbl. f. Klin. Med., No. 7, 1890.) 



284 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

mucous membrane of the intestinal tract must share in the 
action of the skin; therefore, sulphate of magnesium must 
be administered in doses sufficient to produce three or four 
daily evacuations, or calomel in small doses frequently re- 
peated for the purpose of obtaining the same result. The 
arterial tension must be reduced by nitrites, particularly when 
there are cerebral symptoms ; besides aconite in frequent one- 
quarter-minim doses, small doses of opium frequently given, 
or chloral hydrate, may be tried for the same purpose. Digi- 
talis must be avoided with the utmost care, but when exhaus- 
tion is threatening, strophantus or sparteine sulphate may be 
administered alongside the nitro-glycerin. Iodide of potas- 
sium acts favorably in the same direction ; the sulpho-ichthyo- 
late of sodium has been recommended for the same purpose 
by Senator, who gives to an adult pills containing from one 
decigramme (gr. iss) to one gramme (gr. xv) daily. 

The greatest care must be bestowed on the diet of the 
patient. Whatever is irritating must be avoided ; for instance, 
alcohol, spice, or iron. The food must be exclusively liquid, 
and compatible with the vulnerable condition of the kidneys. 
As the first products of the metamorphosis of albuminates are 
eliminated through these organs, and some of those products, 
such as phenol, kreatin, and extractive materials in general, 
are positively poisonous, it follows that strongly nitrogenous 
foods — the opposite opinion of Oertel and Loewenmeyer and 
their followers notwithstanding — must be abhorred. No eggs 
must be taken, and, as a rule, no meat ; now and then an excep- 
tion may be made in favor of veal, spring lamb, chicken, fish, 
or oysters ; but, as a rule, the diet in acute nephritis must be 
confined to milk and farinacea. Barley, wheat (stale bread), 
hominy, rice, and potatoes are permissible, also green vege- 
tables and fruit. The beverage consists of water or an 
alkaline mineral water. Lemonade is permissible unless it 
interfere with the digestion of milk. Neither in the acute, 



DISEASES OF THE GENITO-URrNARY ORGANS. 285 

nor subacute, nor chronic form of nephritis must muscu- 
lar exertion be allowed, for it is this that increases the 
metamorphosis of the albuminates. Moderate exercise, 
however, is not contraindicated in the chronic form ; in 
the latter the elimination of albumin is not increased by 
exercise. 

The surrounding air must be fairly warm when the patient 
is in bed, quite warm when he is about. The function of the 
skin must not be suppressed ; a moderate amount of perspira- 
tion is beneficial. Thus it is that there is a constant indica- 
tion for warm bathing and a warm climate, for both diminish 
the labor of the kidneys (as also of the lungs). As a moist 
air interferes with the action of the skin, a dry climate is pref- 
erable. Hot bathing must be avoided except in the occasional 
emergencies of uraemia. 

Subacute nephritis, with its limpid and sometimes copious 
urine, changeable percentage of albumin, occasional oedema 
and gradual diminution of strength, occasional presence of 
arterial contraction, and of cerebral symptoms, is often over- 
looked. It is a frequent sequela of scarlatina and diphtheria. 
Depletion, hot-air and hot- water baths, and iron, which gets 
deposited in the epithelium of the uriniferous tubes (which is 
thereby subjected to premature elimination), must be avoided 
in most instances. Digitalis is contraindicated during high ar- 
terial tension ; indeed, there are but few cases which permit its 
administration. Small doses of opium benefit the circulation 
in most cases of uraemia complicated with high arterial press- 
ure; so do the nitrites (nitro-glycerin), chloral, and sparteine. 
Mercury in small doses (corrosive sublimate, gr. -^ to ^ 
largely diluted, 1 : 6000, or 10,000 at least) may be given daily, 
week after week, and may be combined in afebrile cases with 
small doses of iron. The air must be warm, a dry warm 
climate selected, a warm bath given every day, with gentle 
friction. Large quantities of water, both pure and alkaline, 



286 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

must be shunned, for the functional activity of the kidney 
must be diminished as far as compatible with a normal circu- 
lation. This rule is particularly stringent during the presence 
of local or general dropsy. Here the amount of liquid con- 
sumed ought not to be greater than the quantity of urine dis- 
charged. Mild diaphoretics and purgatives will also relieve 
the labor of the kidneys. When the amount of uric acid in 
the urine is persistently so large as to point to the presence 
of a lithaemic disposition, salicylate of sodium may be admin- 
istered daily, to the total (daily) amount of ten or fifteen grains. 

Chronic nephritis is of frequent occurrence. The presence 
of occasional headaches, or vomiting, or a slow convalescence 
from any ailment, is suspicious, and calls for the examination 
of the urine. As albuminuria is not always present, and the 
amount of albumin very changeable, that examination must 
be repeated at short intervals. The absence of dropsy or 
oedema proves nothing at all, particularly in the very young 
infant, in whom chronic nephritis without dropsy is a frequent 
occurrence after pleurisy, pneumonia, erysipelas, or in syphilis. 
Indeed, the most dangerous cases are those in which no drop- 
sical symptoms are apparent. Many a case of chronic nephri- 
tis could be prevented by the discovery of the acute or sub- 
acute stage preceding it, and by heeding its many causes. 
Of late I have seen a few cases complicating or rather depend- 
ing on purpura, in which evidently the presence of small 
hemorrhages in the renal tissue gave rise to the initial irrita- 
tion. In these cases the constant use of phosphorus (gr. y^-g- 
twice or three times daily) administered during two or three 
months in succession added greatly to the final recovery. 

Now and then a case of chronic nephritis will recover. 
The majority of those I have seen getting well took corrosive 
sublimate. Children of five years may safely have one- 
fiftieth of a grain in half an ounce of water three or four 
times daily for many weeks in succession. When its inter- 



DISEASES OF THE GENITOURINARY ORGANS. 287 

mission is deemed advisable, or together with the mercury, 
iodide of potassium may be given in doses of six or ten grains 
daily. At the same time iron may be administered, the 
chloride (or one of the milder preparations), from ten to 
twenty minims of the tincture daily. A gentle stimulation of 
the kidneys by preparations of juniper, or the bitartrate or 
citrate of potassium, is advisable. Strong irritation of the 
kidneys must be avoided; digitalis is apt to do harm, except 
in complications with valvular lesions of the heart. To in- 
crease diuresis through strengthening the action of the heart, 
sparteine or caffeine render better services ; the latter, however, 
must be carefully avoided when there are any cerebral 
symptoms whatsoever. Among the best diuretics, through for- 
tifying the heart while diminishing arterial tension, is nitro- 
glycerin. To combat the latter condition, small doses of opium 
are often useful. In cases of obstinate vomiting it is often 
the only reliable remedy. 

Chronic nephritis is apt to call for immediate and strong 
measures during some of its worst sequelae. Uraemia (oc- 
casioned by the accumulation of urea in the blood, the pres- 
ence of cerebral oedema, of arterial contraction and heightened 
blood-pressure, and by reflex irritation of the motory centres) 
results in vomiting, diarrhoea, coma, and convulsions. Strong 
purgatives may be required at once (calomel, gr. v to x ; elate- 
rium, gr. -^-, or croton oil, gr. -fa to -fa every hour, to be fol- 
lowed by sulphate of magnesium), or strong diaphoretics (hot- 
air bath, hot-water bath, hot-water pack, pilocarpine, subcuta- 
neously, in doses of from a fifteenth to an eighth of a grain), 
and occasionally, when the symptoms of cerebral hyperaernia 
predominate, a few leeches to the septum narium (the preferable 
place), or the mastoid processes, will save a case from imminent 
destruction. When, however, much water is eliminated from 
the body through all these procedures, a new supply must be 
introduced either by the stomach or by the rectum. Injec- 



288 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

tioDS into the subcutaneous tissue of large quantities of salt 
water, which have been advised for that purpose, I have not 
had an occasion to require or recommend. Other sequelae or 
complications have each their own indications ; oedema of the 
glottis cannot wait for the effect of the above medication, 
and demands either scarification or intubation. Hydroperi- 
cardium and hydrothorax require paracentesis when the symp- 
toms are urgent. 

The frequency of renal calculi has been alluded to before. 
Indeed, they are quite common, have been observed to occur 
in the foetus, and give rise to many attacks of screaming spells, 
with dysuria, local pain, retraction of the testicles, to the oc- 
casional presence of pus, blood, and gravel in the urine, and 
to vomiting and convulsions. Most of them consist of uric 
acid (very few of oxalates, cystin, or the phosphate of ammo- 
nium and magnesium), and have their positive indications for 
treatment. Particularly in those cases which occur in gouty 
families, the diet has to be limited to but a moderate quantity 
of strongly nitrogenous food. Meat may be permitted once a 
day, white rather more than black. Celery, parsley, aspara- 
gus, and all irritants must be avoided. The patients must be 
encouraged to drink much water, alkaline waters to be pre- 
ferred. All of these contain more sodium than potassium; 
this latter having a greater affinity to uric acid, the bicarbo- 
nate of potassium, in daily quantities of from ten to twenty 
grains, may be given in Seltzer, Vichy, Bethesda, Poland, or 
Waukesha water, large amounts of which ought to be admin- 
istered. The natural lithia waters contain less than the occa- 
sion calls for; the carbonate of lithia taken during a day 
ought to amount to from three to eight grains. Thus the 
artificial lithia waters, if carefully prepared, have the advan- 
tage over those furnished by nature. 

The presence of a stone in the kidney, besides giving rise to 
the symptoms enumerated above, may produce renal catarrh, 



DISEASES OF THE GENITOURINARY ORGANS. 289 

and secondary catarrh in the ureter and the bladder. When 
it leads to pyelitis or pyelonephritis, surgical interference is 
called for. When one of the kidneys is healthy, nephrotomy 
or nephrectomy may save life. 

Of cystitis, infancy and childhood exhibit every possible 
form, from the catarrhal to the ulcerous or diphtheritic. It is 
more frequent than Ashby is willing to admit. Exposure to 
low temperatures, chilling of the parts by sitting on cold 
stones or the wet grass, trauma, vulvo-vaginitis, the adminis- 
tration of cantharides or other irritants, the drinking of beer, 
severe indigestion, typhoid fever, variola, or diphtheria, and 
the presence of stone in the bladder are just as many causes. 
Dysuria, retention or incontinence, vesical and rectal tenesmus, 
the presence of mucus, pus, and blood in the urine, fever, and 
secondary peritonitis or " typhoid" symptoms are among the 
possibilities. Trauma demands absolute rest in bed, and 
either cold or warm applications, besides opium, which may 
be administered internally or in suppositories ; exposure 
(" cold") : warm bathing, diuretics and a narcotic ; the cystitis 
of infectious fevers : rest in bed and tonics ; that following 
the use of cantharides (administered internally or in vesica- 
tories) : from two to ten grains of camphor daily, internally ; 
severe indigestion : the correction of the alimentary disturb- 
ances by abstinence, purgatives, and plenty of water ; hyper- 
acidity of the urine : the use of alkaline waters ; hyperalkalin- 
ity : that of hydrochloric acid ; vesical calculus : its removal, pref- 
erably by the suprapubic operation. In most cases the patient 
ought to be kept in bed, to drink plenty of carbonated alka- 
line water, abstain from cold beverages, live mostly on milk 
and farinaceous food, keep his body warm, particularly abdo- 
men and feet, take a dose of calomel, and an opiate for oc- 
casional relief. But by far the best symptomatic remedy in 
the spasmodic pain of cystitis is hyoscyamus ; from two to 
four grains of the extract may be taken daily for an indefinite 

19 



290 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

period. The chronic cases require the internal use of boracic 
acid or chlorate of potassium (from 15 to 30 grains daily), 
turpentine, gallic or tannic acid, uva ursi, and salol or 
salicylates; the latter if there be no nephritis at the same time. 
In a number of instances the local treatment of the bladder is 
indispensable; the bladder may be washed out with warm 
water, or a warm solution of boracic acid (two or three per 
cent.), or nitrate of silver (one-quarter or one-half of one per 
cent.). This procedure is best performed under chloroform. 

Some of the symptoms met with in cystitis may occur with- 
out the presence of the latter. Painful spasm during mictu- 
rition, retention of the urine, or incontinence are very frequent 
under the influence of quite a number of different conditions ; 
it is upon the latter that the treatment depends. The urine 
may contain, besides a superabundance of uric acid, salts or 
bile, or irritants of a nature which cannot always be deter- 
mined accurately. Thus, urticaria of the surface, when re- 
sulting from ingesta, is quite often complicated with vesical 
spasm, so that it appears that the same cause acted simultane- 
ously on the external and internal integuments. Dysuria may 
also depend upon a painful condition of the urethra, resulting 
from acidity of the urine or the transmission of a vulvo- 
vaginitis, or congenital contraction of the urethral orifice or 
adhesion (mostly acquired) of the labia majora, which is easily 
corrected, or a balanitis resulting from the irritating effect of 
urine retained round the glans penis by phimosis. The in- 
dications for treatment in all of these cases are so plain that 
the enumeration of the etiological factors appears to be suffi- 
cient. There are besides cases of " irritable bladder" as well 
as in the adult, in which the result of the treatment gives 
sometimes the explanation of the cause. In a few cases the 
introduction of a catheter was sufficient to relieve the spasm 
of the neck, in others the administration of hyoscyamus 
proved satisfactory. 



DISEASES OF THE GENITO- URINARY ORGANS. 291 

Retention of urine by local atony and paralysis is rare in 
children, except by hyperextension during school hours ; still, 
it may occur in the course of spinal diseases. Now and then 
there are mechanical obstacles. In the newly-born the collicu- 
lus seminalis is often quite large and requires the introduction 
of a sound. Large stones in the bladder, or a smaller one 
near the neck, or one impacted in the urethra, or a string tied 
round the penis and buried in the swollen tissue, or epithelial 
closure of the urethral orifice, or an oedematous prepuce are 
more or less amenable to a diagnosis and speedy amelioration. 
The injection of warm or cold water into the bladder, warm 
bathing or hip-bath, the correction of the epithelial adhesion 
of the prepuce, and the use of the catheter or sound find their 
ready indications. Retention during infectious or cerebral 
diseases requires great attention. Unconsciousness is a fre- 
quent cause, and frequent percussion of the bladder ought to 
be resorted to when the brain becomes insensible to the expan- 
sion of the organ. 

Evidently the causes of retention are very numerous ; one of 
the most puzzling cases was one in which the accumulation of 
urine was very great. The introduction of an elastic catheter, 
though it entered to its full length, availed nothing ; a metal 
catheter entered with difficulty until it suddenly appeared to 
overcome a difficulty, and the urine was expelled with great 
force. The autopsy gave the explanation of the singular 
occurrence. The whole bladder was lined with a thick diph- 
theritic membrane, which was easily detached but did not admit 
the elastic catheter. This was deflected along the wall of the 
bladder, while the silver catheter succeeded in perforating 
the pseudo-membrane. 

The great variety of the causes of incontinence of urine 
requires tact and discrimination in the selection of remedies. 
General ansemia and muscular debility indicate a diet carefully 
selected for its nutritiousness and digestibility. Gentle mas- 



292 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

sage of the whole body, sponging with alcohol and water (1 : 6) 
or with water, and efficient friction with thick towels, sea- 
bathing, and the use of medicinal roborants, such as iron or 
arsenious acid, will always prove beneficial. The elixir pepsini, 
bismuthi, et strychninse of the National Formulary is a good 
preparation in insufficient gastric digestion, with atony of 
the stomach; a child of three years may take a teaspoonful 
three times a day. 

Attention must be paid to the capacity of the bladder. In 
every case, particularly in the evening, the quantity of fluid 
must be restricted. The sigmoid flexure and the rectum must 
be empty in the night, and the patient should be encouraged 
to evacuate both bladder and rectum before retiring. After a 
few hours' sleep the children ought to be taken up and roused 
sufficiently for both purposes. 

Muscular debility of the neck of the bladder (sphincter) 
requires general and local stimulation. Strychnine or other 
preparations of mix vomica prove effective to a certain extent 
by improving both the general innervation and the appetite ; 
in desperate cases an occasional subcutaneous injection into the 
perineum (gr. ^ to -fa) has rendered good service ; an ointment 
of one part of extract of nux vomica in from ten to sixteen parts 
of fat, introduced into the rectum (size of a coffee or lima bean) 
several times daily, will also act well and can be continued for 
some time. The same indication is fulfilled by ergot, the fluid 
or the solid extract of which may be employed internally. 
The interrupted electrical current is perhaps the most power- 
ful local stimulant; one of the electrodes must be applied to 
the perineum, the other to the hypogastrium or the lumbar 
region. The advice to apply the negative pole to the interior 
of the urethra or bladder and the positive somewhere exter- 
nally is bad, because of the danger of urethritis and cystitis. 

Whenever there is oxalic acid or sugar or an excess of urates 
and phosphates in the urine, the source of the disturbance 



DISEASES OF THE GENITOURINARY ORGANS. 293 

must be attended to. The digestive disorders forming the 
source of the anomalous condition require a corresponding 
change in the diet (diminution of nitrogenous food) or cor- 
rection of the functional disorders of the stomach and liver. 
Until that can be accomplished the prognosis is very uncertain. 
Vesical catarrh, nephritis, and the presence of a calculus in 
either the kidney or the bladder have their own indications. 
The hyperesthesia of the body of the bladder, complicated or 
not with catarrh, — it is often found without it, — requires bel- 
ladonna or its alkaloid. Both belladonna and atropine are 
tolerated in much larger doses by children, in proportion to 
their size or age, than by adults. In many cases a single even- 
ing dose of extract of belladonna (gr. J to f to 1) or sulphate 
of atropine (gr. y^-g- to ^) answers well, sometimes to an unex- 
pected degree. Bromide of potassium (gr. vi to xxv), camphor 
(gr. ii to v), extract, humuli fluidum (*% iv to x), or the elixir 
humuli of the National Formulary, in teaspoonful doses, given 
at bedtime, answer a similar purpose. 

Causes of reflex contraction located in the vagina, penis, or 
rectum require local correction. Vaginal catarrh is as obsti- 
nate because of its inaccessibility as it is frequent. Polypoid 
excrescences about the vagina or in the urethra (of the female) 
must be removed ; if there be phimosis, circumcision is re- 
quired. But a great many cases which are presented for that 
purpose can easily be remedied by gentle dilatation of the pre- 
puce. Firm adhesion of the prepuce requires careful detach- 
ing. Intestinal worms must be expelled, and the fact remem- 
bered that oxyuris has its original seat in the upper part of the 
colon and the lower part of the ileum, so that rectal injections 
have but a temporary effect in most cases. Fissure of the rec- 
tum, mostly of small size and located posteriorly, requires 
forcible dilatation, — a procedure which demands little time 
and no ansesthetic, but is very efficient. 

Irritability of the neck of the bladder and the prostatic 



294 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

part of the urethra has been treated by Henry Thompson 
with cauterization by means of a two-per-cent. solution of 
nitrate of silver. A solution of one part in a thousand of 
distilled water will be found sufficient, or a solution of one or 
two parts of tannin or alum in a hundred. Still, it is a better 
plan lo introduce either an elastic catheter or a metal sound 
into the bladder, every few days, for two or four minutes. A 
few drops of a solution of cocaine instilled into and distrib- 
uted in the urethra a few minutes before the insertion of the 
instrument will in many cases render general anaesthesia super- 
fluous. 

The latter, however, cannot always be dispensed with. In 
the case of a girl of three years, with chronic catarrh of the 
bladder and incontinence, anaesthesia was required a dozen 
times, for two purposes, — first, to inject a solution of nitrate 
of silver (1 : 1000) into the bladder, and, secondly, to dilate 
forcibly, with increasing amounts of water, the organ, which 
had habituated itself not to hold more than a few drachms of 
fluid at a time. 

Masturbation, which is so frequently the cause of irritation 
of the prostatic portion and thereby of incontinence, has its 
own indications. Its cure is by no means easy. Infants can 
be watched and forcible prevention of self-abuse (mostly by 
the thighs or hands) exercised ; but children of more advanced 
years require an unusual amount of firmness and supervision. 
Bodily punishment will avail but little; in the treatment of 
incontinence from whatsoever cause, nothing. 

The development of the genital organs begins in the sixth 
week of embryonic life, that of the urorectal septum, by which 
the urethra of the penis is formed, about the middle of the third 
month. About the same time the anterior part of the urethra 
is developed by the invagination of the epidermoid integument 
of the glans penis. This invagination extends backward to 
the valvula Guerin in the fossa navicularis. Here, where the 



DISEASES OF THE GENITOURINARY ORGANS. 295 

two parts of the urethra are to meet, the opportunity is furnished 
for the occurrence of many anomalies. 

That invagination may not take place at all. In that case 
there is no indication of an anterior urethra. There may be a 
superficial epithelial obstruction of the urethra after it has been 
formed, with retention of urine behind it; or a partial con- 
traction or narrowness of the external orifice, particularly in 
cases of genuine phimosis ; or a genuine stricture in the pars 
cavernosa, of which instances have been reported by Guyon, 
Englisch, and Demme; or an extensive obstruction mostly 
complicated with rectal anomalies, and retention of urine, 
dilatation of the ureters and renal pelves ; or, finally (in a few 
reported cases), obstruction of the neck of the bladder, with 
the same disturbances unless the urachus be forcibly kept open. 

The emission of urine begins about the middle of foetal 
life. Sometimes the connection of the two parts of the urethra 
has not been established ; in that case there is a dilatation be- 
hind the fossa navicularis with a constantly-growing lake of 
urine. Its pressure may succeed in breaking through the 
obstacle with or without the formation of a valve, or it will 
burst the lower wall of the urethra behind the obstacle and 
form a mild form of hypospadias. If the urethra be per- 
forated farther back, the hypospadias may be scrotal or perineal. 
That hypospadias may occur in this way, and not only by an 
arrest of development, is proven by the occurrence of cicatrices, 
and such contraction as depends on cicatrization only. 

Many of these anomalies are the subjects of surgical inter- 
ference. Fortunately, all of them are but rare, as the careful 
reports gathered by Kauffmann in " Deutsche Chirurgie," and 
Boker in " Gerhardt's Manual" will prove. Epithelial ob- 
struction of the external orifice can be remedied by puncturing 
and dilatation of the external orifice; one such case I have 
seen thirty years ago, and never since. Membranous obstruc- 
tion in the fossa navicularis has been pierced ; even a case of 



296 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

foetal imperforation of the glans penis has been perforated by 
Rauchfuss with apparent success. Congenital strictures have 
been treated with bougies. The narrow orifices of hypo- 
spadias have been dilated with bougies, or the knife, or both, 
and laminaria tents used to render the effect permanent. And 
hypospadias has been greatly benefited by operative procedures, 
with better success in modern times than the plastic operations 
of DiefFenbach could boast of. 

The prepuce begins to be evolved about the end of the third 
and in the beginning of the fourth month of embryonic life. 
Within a month afterwards it extends to the middle of the 
glans. Its covering epithelia are pavement. They form 
from six to eight superjacent layers, and extend as far as the 
urethra and sometimes into the fossa navicularis. They are 
also those which constitute the more or less numerous accumu- 
lations, principally about the corona glandis, which were 
formerly taken to be fat, the so-called epithelial pearls. They 
are met with as early as the fifth month of uterogestation. 
They are sometimes so large as to raise the adjoining part of 
the prepuce from the surface of the glans and to form small 
cavities around themselves, thus contributing to the spon- 
taneous separation of the preputial adhesions. 

These adhesions are vastly more frequently soft agglutina- 
tions than solid unions. The causation is simple: as the pre- 
puce and glans are in close juxtaposition, the epithelia of both 
remain moist, and thus become coherent. It is only in those 
cases in which the prepuce does not snugly cover the glans — 
for instance in hypospadias and epispadias — that no, or but 
partial, cohesion takes place. Still, there are cases in which 
the union of the two surfaces becomes quite firm, partly in 
consequence of the occurrence of an inflammatory exudation, 
and partly because of the existence of an extraordinary amount 
of superficial papillae, which, according to Englisch, grasp and 
join each other. Thus the soft cohesion of the prepuce and 



DISEASES OF THE GENITOURINARY ORGANS. 297 

glans penis is a physiological condition, and therefore met with 
in almost every male child. The degree, however, to which 
it is developed is liable to differ. The prepuce of the newly- 
born being long, it may cover the whole glans down to the 
orifice of the urethra, and then by its overlapping adhesion 
give rise to retention of urine, and in consequence of irritation 
by urine, and of the traction invariably connected with the 
slightest changes in the shape of the organ during micturition, 
to pain, redness, muco-purulent secretion, sometimes moderate 
extravasation, and erections which again produce a local irri- 
tation of the surface. It is the erections, when frequently 
repeated, and when occurring more normally in later years, 
combined with the effects of the cavity formations round the 
epithelial pearls, which usher in the gradual and final separa- 
tion of the prepuce from the glans penis. That process takes 
place between about the ninth and thirteenth year of life. 
Thus, in the vast majority of cases, no interference is required. 
The more gradual the separation takes place the safer it 
proves. It is only artificial disjunction which may become a 
danger by secondary changes. The only reason for inter- 
ference is in retention of urine and balanitis, both of which 
are often found together. The separation succeeds in most 
cases quite easily by holding the glans gently but firmly be- 
tween the fingers and pushing or pulling the prepuce in the 
direction of the corona. Towards the end of the operation 
the pearls make their appearance; the separation, however, 
must be completed without interfering with them, and the 
prepuce then carried forward again to avoid paraphimosis; for 
there will be some slight oedema by which the latter might be 
occasioned. Before that is done, the application of vaseline, 
or zinc or lead ointment, or a dust of boracic acid or subnitrate 
of bismuth, or of a mixture of one part of salicylic acid, fif- 
teen of bismuth, and twenty of talcum, is advisable. Carbolic 
acid is contraindicated because of its tendency to facilitate 



298 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

bleeding, though that be ever so slight. In most cases it is 
best not to repeat the procedure for some time, in order not to 
disturb the healing and hardening process. Every wound or 
tear may bring on cicatrization and secondary phimosis. In 
some cases the separation does not take place quite readily; in 
them a blunt probe introduced between the two layers will 
overcome the obstacle. Probe and fingers will succeed, if care 
and time be taken, not only to accomplish the end in view, 
but also to avoid tearing, bleeding, oedema, and inflammation. 
The occurrence of cicatrization is always a serious matter. I 
have succeeded without it in many more cases than I could 
take notes of; for the number of cases in which you will be 
consulted in reference to the advisability of circuuicision — 
which is one of the modern onslaughts upon the genito-urinary 
organs — is very great. Twenty-nine out of thirty alleged 
cases of unconquerable phimosis are exactly of the kind in 
which a patient reduction and separation prevent both a 
surgical operation and a surgical fee. The solid cohesion which 
requires the use of the knife, and a careful and expert operator, 
is very rare; I have seen but one that was complete, in a life- 
time. I cannot imagine that a total synechia is curable with- 
out a plastic operation, or a total removal of the prepuce after 
its separation ; for new adhesion must follow the operative 
separation in the absence of mucous membrane. 

From what I have said it follows that we cannot recognize 
the existence of an actual phimosis in the young before the 
epithelial agglutination has been relieved. The actual cases 
may exhibit a long or a short prepuce, be partial or total, con- 
genital or acquired, atrophic or hypertrophic. The last 
species is often dependent on changes in the internal lamina 
of the prepuce, which, when originally contracted and tight, 
is subject to inflammatory and exudative processes; the 
atrophic form is due more frequently to a defective develop- 
ment of the integument, which thereby becomes attenuated. 



DISEASES OF THE GENITOURINARY ORGANS. 299 

Both of these forms are liable to be congenital, and either is 
found as well among infants and children as in later life. 
The degree of the phimosis depends upon the development of 
those anomalies, and also upon the degree of the presence of 
the elastic layer described by Reiner and situated between the 
two laminae of the prepuce. 

Phimosis may be acquired by pathological changes of the 
tissue depending on accidental morbid processes. Dropsy 
may so swell the prepuce as to result in it. The frenulum, 
congenitally short or otherwise, may suppurate and cicatrize. 
Inflammation and ulceration from whatever cause, irritation 
and tears following inconsiderate or unsuccessful attempts at 
separating epithelial adhesions, and the cicatrization of cir- 
cumcision wounds are apt to render the edges of the prepuce 
unduly rigid. 

The symptoms of phimosis may be both local and general. 
Irritation by contact with urine, and pouching of the prepuce 
by mechanical retention, is quite frequent. Smegma becomes 
rancid when the original epithelial adhesion has been sepa- 
rated. Retention of urine, or incontinence, or both combined, 
are often met with. The former and the spastic dysuria pro- 
duced thereby result in straining, vesical symptoms resembling 
those met with in vesical calculus, prolapsus of the rectum 
with more or less constant tenesmus, the protrusion of hernia, 
the formation of struma, have been observed. Like balanitis, 
which is frequent, cystitis and hematuria have been observed. 
The local irritation gives rise to erection, sexual excitement, and 
masturbation in the youngest of infants. Headaches are said 
to be frequent and temporary, and permanent nervous symp- 
toms in great numbers have been attributed to phimosis. It 
has become quite customary, though less so to-day than ten 
years ago, to attribute severe nervous derangements to it. A 
London neurologist has made the statement that in twenty- 
five cases of epilepsy he found congenital phimosis eleven 



300 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

tiroes. The so-called reflex paralysis from genito-urinary 
causes has played and is still playing an important part in 
American pathology. Numerous cases of infantile poliomy- 
elitis and cerebral paralysis, spastic paraplegia and paralysis, 
chorea, epilepsy, contractures, and idiocy have been explained 
by the presence of phimosis. The numerous cases alluded 
to of alleged phimosis, in which the separation of the pre- 
putial adhesion and apparent phimosis was easily accomplished, 
were exactly such as had been condemned to be operated upon 
for a serious spinal or cerebral disease. There was a time 
when, in a New York medical society, one of the authors of 
the theory of genito-urinary reflex paralysis related cases of 
contracture and convulsions. When reminded of his cases 
being convulsive and not paralytic, he retorted he was no 
physiological theorist, but he cured his patients. In another 
meeting, years afterwards, I stated that 1 had never seen a 
case that obliged me to assume a causal connection between 
paralysis or contraction on one hand, and phimosis on the 
other, and was sustained by neurologists of rank, who also 
denied ever having seen a case which necessitated the assump- 
tion of a genito-urinary etiology. Still the bugbear is alive 
yet, many a prepuce is sacrificed, many a fee pocketed, many 
a diagnosis not made, and many a case either procrastinated or 
not cured. 

Many a case of moderate phimosis is best treated by the 
gentle method of gradual retraction, many a one is improved 
by the normal erection of micturition, and from other causes. 
Thus it was that dozens of years ago an experienced pediatric 
surgeon, Guersant, could state that he seldom operated for phi- 
mosis before the fourth or fifth year. Forcible dilatation, if 
resulting in fissures of the edge, must be frequently repeated to 
avoid hard cicatrization and consecutive contraction. Such 
cases as are not amenable to that treatment require the knife 
or scissors. The incision of the inner lamina alone, which has 



DISEASES OF THE GENITO-URINARY ORGANS. 301 

been recommended, is very apt to be incomplete, though pain- 
ful, and to lead to swelling and imperfect results. The 
atrophic variety requires a dorsal incision by either knife, 
carried on a director, or a pair of scissors; the inner lamina 
is often not thoroughly divided, and requires the repetition of 
the incision ; when the scissors cannot be carried over the 
whole length of the glans, it has become necessary to first cut 
down on the corona glandis, thus to enable the operator to 
carry the scissors over the entire length. The cut edges are 
mostly subjected to Kocher's continuous suture, and the whole 
surface treated antiseptically with bismuth or corrosive sub- 
limate. The lower corners are mostly rounded off. This is 
particularly necessary in the cases of hypertrophic phimosis 
which are subjected to the same surgical treatment. Most of 
this class, however, demand complete circumcision, care being 
taken that more is removed of the dorsal prepuce than of the 
opposite side, that the inner lamina is separately divided after- 
wards and the epithelial adhesion carefully separated. The 
prepuce must be drawn forward sufficiently to protect the 
glans against being injured ; more than once have I seen it 
mutilated. In one case the mutilated glans became infected 
with diphtheria. The wound must be sutured, and treated 
antiseptically. One of the saddest cases of my whole life, 
and one of persistent distress, was the death from erysipelas 
from that simple operation performed on a boy of three years. 
Infections of circumcision wounds by bacteric poisons are 
quite frequent ; such of diphtheritic invasions I have published 
in my treatise of diphtheria ten years ago, and before that in 
the second volume of "Gerhardt's Manual;" many more I 
have seen since; and syphilis and tuberculosis have been 
known to follow many instances of either surgical or, more 
frequently, ritualistic circumcision. 

Diphtheria of the prepuce, or rather the genito-urinary 
organs in general, the female included, may occur as an origi- 



302 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

nally local affection — such as those alluded to — or a part of 
the general infectious diseases. The latter are mainly diph- 
theria, scarlatina, and measles. The last named is the very 
malady which appears to predispose the system to the most 
vehement forms of local invasions. The aphthous vulvitis of 
little girls, and noma, are mostly found after measles, and 
diphtheria, when found after the same eruption, is more apt 
to destroy life, with general symptoms. In many cases of 
localized diphtheria, however, the constitutional symptoms are 
but few, provided that effective local treatment is immediately 
resorted to. Absolute cleanliness of the parts, sponging and 
bathing, is first in order, after that, local disinfection. Appli- 
cations of lime-water will suffice for mild cases; solutions of 
one or two parts of sulpho-carbolate of zinc in one hundred 
of water, or from one- to five-per-cent. solutions in water of 
acetico-tartrate of aluminium, will act well. These two may 
be used to advantage as a vaginal injection in the case of the 
smallest girls. The point of a small hard-rubber syringe can 
be lengthened by a thin india-rubber tube, from half an inch 
to an inch in length, which passes the hymen easily and 
permits an irrigation of the otherwise inaccessible parts. In 
many cases solutions of the bichloride of mercury proved suc- 
cessful : for occasional applications, of one in from three to 
five hundred of water ; for frequent use, of one in from two to 
five thousand. Iodoform as a powder, or in from eight to 
fifteen parts of vaseline, has rendered very effective services. 

Noma of the vulva and vagina requires more determined 
local treatment, besides assiduous roborant and stimulant ad- 
ministrations. Mineral acids in full strength, strong solu- 
tions of corrosive sublimate, have proved efficient in many 
cases in which the progress of the disease was not too rapid. 
I have had most successes with the actual cautery. Pyok- 
tanin I have used lately in a case of noma of the face, and in 
one of the vulva, and found it absolutely worthless. 



DISEASES OF THE GENITO- URINARY ORGANS. 303 

Paraphimosis is always an artefact. The separation of the 
epithelial congenital adhesion and the dilatation of a phimo- 
sis are liable to be followed by oedematous swelling. In both 
cases the prepuce must be drawn back over the glans. If 
that be omitted, the prepuce — relatively long in the child — 
becomes swelled, and often gangrenous. Fortunately, the penis 
itself is not often drawn into that process. For the purpose 
of reduction, the glans penis, which is considerably swelled, is 
persistently compressed by both hands while the prepuce is 
drawn forward. A good deal of force is sometimes required, 
and not infrequently an anaesthetic. Sometimes gradual com- 
pression by bandages (cotton or rubber) must precede the 
attempt at reduction; in some cases, however, a careful inci- 
sion of the prepuce, the more careful when no director can be 
introduced between glans and prepuce, is unavoidable to 
relieve the constriction. 

The treatment of the more common forms of balanitis and 
balano-posthitis, occasioned by the decomposition of smegma, 
or masturbation, or gonorrhoea, or trauma, such as the constric- 
tion of the organ by a string, is not always quite simple. 
When there is much oedema it may become necessary to incise 
the prepuce to get at the sore surface. In most cases, how- 
ever, astringent or disinfectant solutions can be applied readily 
either directly or through a small syringe. Solutions of 
acetate of lead, sulphate of zinc, alum, tannin, the sulpho- 
carbolate of zinc, the acetico-tartrate of aluminium can be 
employed in different strength. Among the poor, when assidu- 
ous attention is out of the question, ointments or powders are 
preferable. Ointments are best made for this purpose with 
vaseline. Warm bathing and sponging will improve the 
chances of rapid improvement. 

A similar local treatment is adapted to the vulvar and vaginal 
catarrh of both the adult and the infant or child. It is very 
common among the latter, and quite obstinate because of the 



304 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

comparative inaccessibility of the parts, no matter whether the 
catarrh is simple or specific. The causes of the former are very 
various. A predisposition may depend on the structural de- 
bility, with chronic inflammation, of most tissues, which we are 
in the habit of calling scrofulous. Local exposure to cold, sit- 
ting on house-stoops, the irritation brought on by masturbation, 
or by foreign bodies, mud, cotton, carpet-fuzz, glass, wood, all 
of which I have found in the narrowest vaginae ; also oxyuris 
emigrating from the rectum, the use of soiled cloths and towels, 
and the neglect of the most common cleanliness, are among 
the most frequent causes of vaginal catarrh. Specific vaginal 
catarrh (gonorrhceal kolpitis) is by no means rare. The in- 
fection, though most often indirect, and conveyed by towels, 
bed-sheets, etc., gives rise, nevertheless, even in the smallest 
children, to glandular swellings, endo- and parametritis and 
peritonitis, also to urethritis, though the latter appears to be less 
common in children than in adults. That contagion should 
take place through the air, according to Bouchard, I have never 
been able to observe. Besides the local treatment, in conform- 
ity with the details given above, absolute cleanliness of the 
body and clothing, and frequent (general and hip) baths are 
required. Masturbation must be guarded against, and foreign 
bodies sought out and removed. Rectal oxyurides require in- 
jections with water, or garlic decoctions, or cod-liver oil. They 
must be frequently repeated, and resumed after the intermis- 
sion of weeks, because of the repeated immigration into the 
rectum from the upper parts of the intestine, where the neraa- 
toid has its habitat. In specific cases the transmission of the 
virus to the eyes and to other persons must be guarded against. 
To reach the recesses of the vagina, partial or total removal of 
the hymen has been advised ; but I have met with no such in- 
dications. Besides the solutions enumerated above, nitrate of 
silver has been advised. I have used it, in solutions of one in 
from five hundred to a thousand, in a number of cases of ulcer- 



DISEASES OF THE GENITOURINARY ORGANS. 305 

ative catarrh. In some the restitution of the superficial losses 
of substance appeared to be more rapid. In stronger solutions 
and in substance it has been employed in tubercular ulcera- 
tions, in reference to which I have no experience. In many- 
cases of vaginal catarrh the surrounding parts are sore and 
suppurating, or eczematous. Lead or bismuth ointments, or 
bismuth powder, with or without salicylic acid, will effect a 
cure of that complication. 

A frequent result of vaginal catarrh of long standing is a 
moderate degree of atresia of the vagina. It is usually of an 
epithelial character only, and can be remedied by tearing the 
adhesion with both hands, or by piercing with a probe and 
dilating the artificial opening. Astringent applications will 
prevent the renewal of the closure. Diphtheritic inflamma- 
tion of the vulva and vagina I have known to result in pretty 
firm occlusion. In one case the reopening required some force, 
and the continued use of bougies and astringent applications to 
prevent a repetition of the union. The imperforate condition 
of the hymen, mostly congenital, is but the same process of epi- 
thelial and inflammatory cohesion accomplished during foetal 
life. According to its early or later formation, and according 
to the presence or absence of vaginal complications, it requires 
either the probe or the knife. Such a complication is mostly 
the result of either an arrest of development or inflammatory 
malformation. An early adhesive inflammation of the vagina 
will obstruct it in its entire length, or a transverse obstruction 
of the ducts of Muller may produce an absence of the vagina 
below the external os uteri. 

Vaginal hemorrhage, of a slight degree, has been observed 
in the newly-born, without any complication, least so with 
bleeding from other organs. It is mostly very slight. In 
masturbating infants and children, and some of those who 
suffer from a severe vaginal catarrh, some blood may be noticed. 
It requires no special treatment ; nor was there an indication or 

20 



306 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

an opportunity to interfere in the very rare cases of genuine 
menstruation in the very young, which have been reported. 

In connection with vaginal catarrh I mentioned masturba- 
tion as one of the causes. Still, it is not only a cause in some 
cases ; in many others it is its effect. Indeed, masturbation is 
so frequent that a few words on the subject may be deemed 
permissible at this place. But lately, in the April, 1890, num- 
ber of the Archives of Pediatrics, a clinical lecture of mine 
was published. There, and in a previous essay published in 
the American Journal of Diseases of Children and Women, of 
1875, I demonstrated the frequency of that habit in infants 
and children ; more in girls of the earliest infancy, more in 
boys of advancing years, and a variety of causes leading to it. 
Such are local irritation of the genitals in the very youngest, 
excitation in those older, feather beds, excess of animal food, 
and stimulating beverages, rancid smegma, eruptions on the 
penis, vaginal and vesical catarrh, renal calculi, preputial 
adhesion, phimosis, oxyuris, and constipation. Among rem- 
edies, I recommended the relief of the causes as enumerated, 
and partly alluded to in the course of these remarks : cooling 
diet and coverings, attention to kidneys, bladder, and rectum, 
relief of external irritation by clothing, removal from the bed 
upon awakening, cold bathing and sponging, mechanical pre- 
vention, and timely punishment. 

Cryjptorchis is the absence of the testicle from the scrotum. 
Normally it descends in the ninth month of utero-gestation, or 
during the first weeks of extra-uterine life, but sometimes at a 
later period, or not at all. In the latter case, particularly 
when incarcerated in the canal, it is apt to undergo malignant 
degeneration. When in its descensus it gets under the femoral 
arch, resembling a crural hernia, or to the perineum, it is sub- 
ject to inflammation, and requires the application of ice, and 
occasionally a local depletion, or a puncture for the relief of 
effusion ; and sedatives for the removal of reflex convulsions. 



DISEASES OF THE GENITO-URINAEY ORGANS. 307 

In most cases of incomplete descensus the testicle is found in 
the inguinal canal, slightly movable, and often complicated 
with hernia. No matter whether this complication is present 
or not, the treatment consists in the application and con- 
stant wearing of a truss so adjusted as to keep the testicle 
below and the intestine above. Its effect can be enhanced by 
frequent and gentle massage. This simple treatment I have 
found effective in so many cases that Ashby and Wright's ad- 
vice — not to rely on it, but to operate and either fix the testicle 
below or remove it altogether — appears to me almost incom- 
prehensible. Indeed, I can approve of their view only in those 
cases in which the testicle and intestine are bound by adhesions. 

Orchitis is occasionally found in children. The acute form 
is either traumatic, or alternates with parotitis, or no cause is 
obvious. The treatment has to be conducted on general prin- 
ciples, and consists in the local use of ice, of purgatives, and, 
occasionally, of antipyretics and narcotics. Leeches resulted, in 
a few of my cases, in extensive swelling of the scrotum. Chronic 
orchitis is mostly combined with epididymitis, the result of 
trauma combined with a scrofulous disposition. It is apt to lead 
to induration, caseation, and tuberculization. If that occurs, 
the organ ought to be removed to avoid general tuberculosis. 

Primary tuberculosis appears to begin mostly in the epididy- 
mis, and requires removal, as well as dermoids, sarcomata, and 
carcinomata. Of the latter, I have lately seen a case in a boy 
of four years. It was removed nineteen months ago, and no 
new local trouble has arisen. Not even the lymph-bodies of 
the neighborhood are attacked, but the disease appears to have 
invaded the lungs. 

Syphilis of the testes requires a strict anti-syphilitic treat- 
ment. There is no objection to the internal administration of 
mercurials and iodides ; but in the first few weeks a daily hy- 
podermic injection of a soluble mercurial salt will improve the 
chances of recovery. 



308 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

Hydrocele is a frequent occurrence. A few drops of serum 
are normally found in the tunica vaginalis propria. Larger 
accumulations of serum are met with in more than ten per 
cent, of all male infants, — mostly on the right side, seldom 
on both. In the majority of cases there is no longer a com- 
munication with the abdominal cavity. When it remains, a 
hernia may complicate the hydrocele, and the diagnosis may 
be more difficult because, in such a case, the fluid is apt to re- 
turn occasionally into the abdomen. Spontaneous absorption 
is not very rare, and suppuration uncommon. I have injected 
alcohol and diluted tincture of iodine, and setoned the scrotum 
with either silver wire or silk. All of these methods are bad. 
Simple punctures, one or more, made once or repeatedly, will 
allow the escape of the fluid, which frequently does not return 
after the first procedure. It is best to dislodge the integument 
a little, so as to have no direct escape of the serum. The cases 
in which the communication with the abdominal cavity is still 
patent require the application of a truss after the serum has 
been allowed to previously return to the .abdomen. 

The pseudoplasms of the young female urogenital organs 
offer no special indications of their own. Tumors of the 
ovaries were mostly found, on operation, to be dermoid cysts, 
and very rarely carcinoma or tuberculosis. The same and 
sarcoma are but rare occurrences in the vagina. Cysts have 
sometimes been found above the hymen, and soft polypi more 
frequently in the urethra. They are either easily recognized 
or mistaken for a simple prolapse of the urethral mucous 
membrane. They give rise to vesical tenesmus and dysuria 
sometimes, and also to (mostly slight) hemorrhages. Evul- 
sion, chromic acid, the scissors, and the actual cautery, now 
and then two of these means combined, have been used. 
Ligature never succeeded in my hands. It would always cut 
through at once, produce some bleeding, and necessitate at 
once some other method. 



DISEASES OF THE RESPIRATORY ORGANS. 309 

VIII. 

DISEASES OF THE RESPIRATORY ORGANS. 

Acute nasal catarrh (acute catarrhal rhinitis) is found 
either as a sporadic or epidemic ailment ; the latter is rarely 
depending on erysipelas, still less frequently on gonorrhoea, 
more frequently in influenza, measles, or whooping-cough. 
The sporadic form is sometimes local and unilateral ; in that 
case it has a local cause, such as a traumatic lesion, a foreign 
body ; when bilateral and general, it is mostly the result of 
sudden thermometric or barometric changes, or exposure. Now 
and then the irritation of trifacial branches of the maxillae 
will, when dentition is abnormal or unusually difficult, give 
rise to vaso-motor and secretory changes of the nasal mucous 
membrane, which is supplied with ramifications of the same 
nerve. Acute nasal catarrh may be attended with high tem- 
peratures, considerable swelling, and obstruction (thus ren- 
dering respiration extremely difficult, particularly when the 
patient is newly born or quite young), and secondary affec- 
tions, such as swelling of the cervical lymph-bodies, acute 
pharyngitis, amygdalitis, and otitis. The indications for 
treatment are various : the local hyperemia and swelling is 
to be reduced, the secretion to be removed, fever to be relieved, 
and secondary affections either to be prevented or treated. 

Hyperemia and swelling may prove dangerous to very 
young babies. In them the nasal cavities are narrow, and so 
easily obstructed by an acute catarrh that now and then a newly- 
born infant that has not yet learned how to breathe through 
the mouth is in danger of suffocating. Some of the cases 
require constant attention ; day and night the mouth must be 
kept open by gentle pressure on the chin to enable the little 
patient to breathe through the mouth until the nares become 



310 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

viable. Particularly in cases where the mucous membrane is 
thickened from birth, or a nasal polypus is present, or a 
swelling of the pharyngeal or the palatine tonsils, the danger 
of suffocation is great. In a single case have I been com- 
pelled to apply the galvano-cautery to the left nasal cavity of 
a newly-born whose acute catarrh obstructed the narrow 
channel. Astringent solutions are indicated for a similar 
purpose, or ointments which may be applied by means of a 
camel's-hair brush. Still, I cannot express much satisfaction at 
the effects obtained. Better is a two-per-cent. solution of 
hydrochlorate of cocaine, which may be applied with a brush, 
or by means of the atomizer, from time to time. Camphor 
inhalations have been praised. The secretion must be re- 
moved now and then by wiping out the nose and bringing on 
sneezing. The wiping out may be done with a probe covered 
with absorbent cotton, the latter to be introduced dry, or 
moistened with an alum or cocaine solution. The passage may 
also be kept viable by a physiological salt solution (1-130), 
or an astringent, or disinfectant wash of alum, sulphate of 
zinc, subnitrate of bismuth, and boracic acid. The latter 
is not always satisfactory. In most cases, it is true, it acts 
very mildly, but I have seen catarrhal secretions increased 
by it. These applications may be made in different ways. 
An atomizer, the nozzle of which is covered with a small 
piece of india-rubber tubing, will do no harm j injections, 
unless made very gently, are liable to injure the ear; irrigation 
by merely emptying a pipette or a small spoonful of a solu- 
tion into the nostril will prove satisfactory. Otherwise the 
rational general treatment of a catarrh may be resorted to: 
moderate temperature of the room (68°-74° F.), moist air 
when the secretion is thick and viscid, or scanty, an occasional 
warm bath, a dose of quinia about noon if there be a consider- 
able rise in the afternoon, an occasional dose of phenacetin or 
antipyrin during the day or small doses of the tincture of 



DISEASES OF THE RESPIRATORY ORGANS. 311 

aconite at intervals of two hours; probably a single dose of 
opium as a sedative and diaphoretic, late in the evening. 

Chronic nasal catarrh derives its therapeutical indications 
from its many occasional causes ; for instance, frequent returns 
of acute catarrh, dusty, cold, and moist air, the pressure of a 
foreign body, or the deviation of the septum. This condition 
may be congenital, even hereditary, or due to a fracture of the 
septum, or to its dislocation from the ethmoid, or vomer, or 
superior maxilla. It results in obstruction, and behind it 
in accumulation of mucus which disintegrates and irritates. 
Other causes of chronic nasal catarrh are enlarged tonsils, 
chronic pharyngeal catarrh, and adenoid vegetations, with their 
influence on respiration, digestion, the sense of smell and 
taste, and intellectual development. Scrofula, tuberculosis, and 
syphilis, with their effects on mucous membranes, bones, and 
cartilages, are frequent causes of chronic nasal catarrh. Less 
frequent are the effects of furunculosis, which is rarer than in 
the adult ; of croupous inflammation ; of diphtheria of the 
nose, which may be met with independently of pharyngeal 
diphtheria or ushering it in ; or of eczema of the upper lip. 

Syphilis, tuberculosis, and scrofula have their own indica- 
tions. Thus, a chronic rhinitis occasioned by these demands 
mercury, arsenic, creasote, cod-liver oil, iron, phosphorus, 
according to general rules. Abscesses are to be opened, the 
small furuncles incised, necrotic bones removed. Foreign 
bodies must be extracted, adenoid vegetations removed, and 
hypertrophied tonsils resected, or — in occasional cases — treated 
with the galvano-cautery. Many a case of chronic nasal 
catarrh will be relieved, or nearly cured, by these measures, or, 
on the other hand, there is many a case of chronic pharyngi- 
tis which gets well through the treatment of the nasal catarrh. 
Indeed, there are very many of these complications in which 
the determination of the primary seat of the affection is very 
difficult, or even impossible. If there be a considerable devi- 



312 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

ation of the septum, not to speak of the excessively rare cases 
of bony union, it must be corrected. In very young infants 
that correction can be accomplished by manual pressure. The 
cleansing of the nasal cavities is of at least as much impor- 
tance as in acute catarrh. They must be washed out from two 
to four times a day with some warm fluid. According to the 
case, this may be salt water, or a solution of boracic acid (two to 
four percent.), or alum (half per cent.), or acetico-tartrate of alu- 
minium (one per cent.). The same precautions must be used 
which were advised above. If larger quantities of the fluid 
be used the injection must be made very gently, and the child 
taught to keep its mouth comfortably open. Chlorate of 
potassium has been used in solutions of from one to three; 
resorcin, of two per cent. ; creasote has been applied similarly; 
iodine or tannin, in combination with glycerin. Cocaine so- 
lutions have been used with good results. Its immediate 
result is evident, and it is better than a merely temporary 
makeshift. What I have seen to do a great deal of good is 
nitrate of silver. A solution of from one-fourth of a grain 
to two grains in an ounce of distilled water may be sprayed 
into the nasal cavity once a day, or every other day. When a 
carious bone is underlying the chronic Catarrh, an iodoform 
ointment (1 : 8 or 15 vaseline) may be applied several times a 
day, to advantage. Hypertrophy of the mucous membrane 
and submucous tissue, with ulcerations or granulations, add 
greatly to the difficulties of the case. Lactic acid in powder 
or strong solutions has the reputation of destroying morbid 
tissues, mainly granulations, and of leaving the healthy tissue 
intact. Still, I cannot say that it has rendered me very appre- 
ciable service in cases I considered adapted to its alleged 
powers. The exuberant tissue will, however, be beneficially 
influenced by an application, every few days, of a solution of 
iodine (1 : 8 or 1 : 4), of iodol or aristol, of subnitrate of bismuth, 
of a strong solution (ninety per cent.) of carbolic acid every 



DISEASES OF THE RESPIRATORY ORGANS. 313 

four or five days, of chromic acid once every week or ten days, 
and last and best, of the galvano-cautery under cocaine anaes- 
thesia. For the purpose of compressing the swelled soft tissues 
and correcting a deviation bougies are also used, made with 
zinc, tannin, or carbolic acid. I must admit that chromic acid 
and the galvano-cautery are my choices in the worst classes of 
cases. Even many cases of ozaena are doing well under their 
influence. Others require the frequent use of stronger solu- 
tions of nitrate of silver as a spray, or hypermanganate of po- 
tassium solutions, or acetico-tartrate of aluminium in one- to 
three-per-cent. solutions, or iodol or aristol insufflations, or a 
combination of a few of these remedies. 

Polypi, either congenital or acquired through chronic catarrh, 
though not frequent, will be met with in every medical prac- 
tice. They are either soft and consist of mucous membrane, 
or harder and are composed of a dense connective tissue. 
Those with an admixture of sarcomatous tissue (not often round 
cells, more frequently spindle-shaped cells with copious 
stroma) are relatively rare. The cold or gal vano-caustic snare 
is required by those which have a rather bulky pedicle. 
Evulsion with a common polypus forceps suffices for those 
which are distinctly pedunculated, and for such as consist in 
the main of mucous membrane. A firm tampon is seldom 
required by excessive hemorrhage after evulsion. In most 
cases the bleeding ceases spontaneously; or a tampon of 
moderate size covered with powdered alum or tannin is de- 
manded ; or the cauterization of the stump with chromic acid, 
either dry or in concentrated solution, by means of a camePs- 
hair brush or a probe covered with absorbent cotton. This 
application may be repeated after a while to guard against a 
return. 

Foreign bodies are often found in the nasal cavities of babies 
and children. Paper-balls, shoe-buttons, dry peas and beans, 
flies and bugs, cherry-stones, and beads are readily admitted. 



314 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

Their diagnosis is by no means always easy. Chronic catarrh, 
being their usual result, gives rise to the mistaken diagnosis 
of caries, syphilis, or tumor. The cases in which the presence 
of a foreign body caused delirium and convulsion, and could be 
taken for meningitis, are, fortunately, rare. In many, chloro- 
form anaesthesia is required to ascertain the nature of the 
difficulty. The consecutive catarrh and ulceration require 
mild or disinfectant washes or injections ; pincers, or the ear- 
spoon, or Daviel's spoon will generally suffice to dislodge the 
foreign body. When the symptoms are urgent (convulsions, 
high fever), an ala nasi has been incised to facilitate the re- 
quired extraction. 

Epistaxis depends on the rupture of one or more blood- 
vessels, either large or small, normal or abnormal. A normal 
blood-vessel may bleed in consequence of a traumatic injury, 
or of an erosion by chronic catarrh, ulceration, diphtheria, or 
syphilis. Bleeding from the nose may point to the presence 
of a polypus, or be the indication of obstruction in distant 
parts of the circulation in the abdomen, the lungs (chronic 
pneumonia, emphysema), the thyroid body, or by cardiac 
disease. The compression of the abdominal viscera by enforced 
confinement in the school-room, overheated and ill-ventilated 
at that, and consecutive constipation are a frequent cause of 
epistaxis. Blood-vessel walls become abnormally fragile in 
constitutional and infectious diseases, such as early chlorosis, 
tuberculosis, hsematophilia, leucocythsernia, general amyloid 
degeneration ; in purpura, scurvy, and typhoid fevers. Per- 
haps the most obstinate form of epistaxis, which is fortu- 
nately infrequent, is that which depends on the congenital 
incompetency of the heart combined with smallness of the 
large arteries, and results in the most serious cases of chloro- 
sis. All these different causes of epistaxis suggest their own 
indications. The constitutional diseases resulting in local 
hemorrhage demand such management as has been indicated 



DISEASES OF THE RESPIRATORY ORGANS. 315 

in other essays of this series. All of them may require local 
treatment. It is obvious that in every case of epistaxis the 
congestion of the nasal mucous membrane must be dimin- 
ished if possible, and the formation of a clot must be facili- 
tated. By raising the arms over the head, and forced inspira- 
tion, the chest is expanded and a large amount of blood accom- 
modated in it; hot hand- and foot-baths have been resorted to 
for a similar purpose. Ice may be applied to neck and throat, 
pieces of ice introduced into the bleeding nostril. The local 
use of water (injection, washing) is not desirable, inasmuch 
as it is liable to prevent the coagulation of the blood on the 
bleeding surface. Solutions of alum or tannin will answer 
better. The use of a tampon is often required to stop the loss 
of blood. The introduction of a wick of absorbent cotton, 
or lint, by means of a pair of fine pincers, or, better, by 
loosely wrapping it round a smooth probe (whalebone or other), 
or of the same covered with alum or tannin, or soaked with 
perchloride or subsulphate of iron (" haemostatic cotton"), 
will sometimes prove satisfactory. In but a few will it be 
found necessary to dose the whole cavity from either side, by 
means of a tampon introduced through the mouth into the 
posterior nares, at the same time obstructing the nose ante- 
riorly. This procedure is not so annoying and irksome as it 
appears to be, because in but a few cases nose-bleeding is 
bilateral. 

Chronic catarrh and ulceration of the nares must be 
treated according to the principles taught above, and the most 
frequent causes of epistaxis among children attended to ac- 
cording to their own indications. I cannot impress too much 
the necessity of attending to the intestinal congestions and 
disorders of school-children. Constipation of a lifetime is 
often the result of the cramped position on an improper chair 
or bench, and of the inability to evacuate the bowels at the 
proper time. Children suffering from constipation, particu- 



316 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

larly those who are affected with what I have describsd as con- 
genital constipation, may require this daily injection and may 
be benefited by an occasional (vegetable) purgative. This is 
sometimes all that is required to relieve their epistaxis. That 
many are relieved only when taken from school and allowed 
the free use of their limbs in open air is self-evident. . Another 
large class of nose-bleeders is that which originally suffered 
from chronic pneumonia or chronic heart-disease with general 
and persistent anaemia. Very many of these cases improve 
instantly under the sufficient use of digitalis and iron. 

Acute laryngeal catarrh, acute laryngitis, is too common a 
disease to justify in these pages a discussion of its etiology or 
diagnosis. In regard to the latter, I refer to a single point only, 
— viz., that of the temperature, which is always elevated. An 
uncomplicated acute laryngeal catarrh is always attended with 
fever, while an uncomplicated laryngeal diphtheria (" pseudo- 
membranous croup") is not so accompanied. Dozens of years 
ago I brought out this fact, and a large experience has since 
convinced me of its reality. The other symptoms are unmis- 
takable, from the different degrees of dyspnoea to those of 
hoarseness or aphonia. The treatment requires the most per- 
fect possible rest. Talking must be prohibited, crying avoided 
if feasible. For that reason, if for no other, opiates are indi- 
cated ; partly to relieve the local irritation which produces 
cough, and partly to secure sleep for the purpose of equal- 
izing circulation and resting the excited muscles. The tem- 
perature of the room ought to be equable, from 68° to 75° F., 
the air moist. The latter eases the large windpipes and pro- 
cures recreation, while dry and cold air increases metamor- 
phosis. Whatever beverages are given must be warm. A 
general warm bath, warm applications (hot water, poultices, 
cold applications which are permitted to become warm), are 
both pleasant and beneficial. Plenty of water ought to be 
furnished, mild alkaline mineral water by preference. An 



DISEASES OF THE RESPIRATORY ORGANS. 317 

infusion of ipecac with bicarbonate of sodium, in small and 
frequent doses, will aid in liquefying a viscid mucous secretion. 

The worst form of the acute catarrh of the larynx gives 
rise to attacks of dyspnoea (" croup"), which occurs quite 
frequently in the night after the children have been asleep for 
some hours. The drying up of the pharyngeal mucus is very 
apt to give rise to both cough and dyspnoea, and therefore it is 
a good plan to wake the patient from time to time sufficiently 
to make him drink. Average moisture of the air may not be 
enough. Water ought to be kept boiling constantly, so as to 
fill the air of the room (or a tent, which ought to be spacious) 
with steam. Spraying the throat with cold water is useless com- 
pared with the effect of warm vapors. That leeches, which I 
used sometimes in bad cases of feverish and croupous catarrh, 
thirty years ago, ever resulted in any good I am not prepared 
to say. But a promptly administered emetic (ipecac, sulphate 
of zinc or copper, turpeth mineral, apomorphia) has often 
relieved the spasmodic dyspnoea accompanying these (mostly 
nocturnal) attacks of pseudo-croup. The effect of. emetics, 
however, and their indispensability have often been exagger- 
ated. Mostly, they are less required for the relief of the 
babies than for tranquillizing the fears of the mother and allow- 
ing the family physician to stay in bed. 

Chronic laryngeal catarrh may develop out of a protracted 
acute catarrh, or the affection may be primarily mild, but 
result at an early time in thickening of tissue. Even at 
the earliest age this process may be observed. One such case 
I saw with Dr. Hopkins, of Brooklyn, in a newly-born baby, 
which got well after the protracted daily administration of a 
few grains of iodide of potassium, after several months only. 
Constant warm applications, or cold ones which are permitted 
to become warm, will favor absorption. Those which are 
complicated with, or perhaps dependent upon, a chronic laryn- 
geal catarrh are often favorably influenced by the use of 



318 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

tincture of pimpinella saxifraga, half a drachm or a drachm 
of which may be taken daily, in ten or twelve doses, in a 
solution of chlorate of potassium, in such a way that the dose 
of the latter be a cautious one, and the dilution in water of 
the tincture be not excessive. This drug has long been "ob- 
solete," but deserves to be reappointed to its former place in 
practice. The majority of such cases will do well when 
being treated with solutions of bicarbonate of sodium or iodide 
of potassium. 

Diphtheritic laryngitis, pseudo-membranous croup. — It is 
not necessary to discuss here pathological questions, or to re- 
assert the histological identity of diphtheria and " croup." 
When pharyngeal diphtheria has reached the larynx in its 
descent, or bronchial diphtheria resulted in its ascent in sud- 
den laryngeal stenosis, the usual antidiphtheritic treatment 
avails but little. That neither general nor local depletion has 
any effect, except that of hopelessly reducing the patient's 
strength, has long been recognized ; also, that vesicatories 
add a new diphtheritic membrane on the surface to those 
on the mucous membranes. Emetics are of no use unless 
a peculiar flapping sound betrays the presence of half- 
detached membrane in the air-passages. In such a case they 
are apt to save life. At all events, I have never been so 
fortunate as to observe the universally beneficent effect attrib- 
uted to their frequent administration in an average case. 
Massage of the larynx has been recommended by Bela Weiss. 
I cannot say that the few cases in which I advised the pro- 
cedure were successful ; it may be that the constant repetition 
of the advice to use mercurial or other ointments over the 
larynx is based on the observation of an occasional good effect 
of the friction (" massage") attending their employment. 
Locally, lactic acid, in more or less saturated solution, has 
been eulogized as a solvent of the membranes in the larynx, 
when often applied either by brush or spray. Most of the cases 



DISEASES OF TIIE RESPIRATORY ORGANS. 319 

in which I have seen it used were not successful, but this un- 
toward result is, unfortunately, not exceptional. I have seen, 
or believe I have seen, papayotin (1) to dissolve membrane 
when applied in a mixture of glycerin and water (aa 2). 
Particularly would that occur in pharyngeal diphtheria slowly 
descending. Lime-water is still used as a spray and has its 
admirers. Lime slaked in a small room, or under a tent, is 
decidedly more effective, for during that process a large 
quantity of lime is carried up and is inhaled ; at the same 
time the softening and solvent effect of the steam is obtained. 
The latter is not always as beneficent as it appears. In many 
the application, externally, of cold water to the neck, or ice- 
bags, is vastly preferable. But in most cases of anaemic 
and highly-nervous children the latter are not tolerated. 
Constant inhalations of turpentine, or carbolic acid, from a 
kettle containing boiling water have impressed me as benefi- 
cial in a large number of cases. In the foundling asylum 
(service of Dr. Reid and Dr. O'Dwyer, Dr. Clark, house physi- 
cian) I have observed a good effect in a few simultaneous 
cases of the inhalations, by heat, of calomel. 

The patient remains in bed as much as possible, and may 
continue such expectorants as he perhaps took for previous 
catarrhal symptoms; may also take diaphoretics, warm bev- 
erages; an occasional opiate for that indication and to procure 
some rest. The continuation of chlorate of potassium, when 
the invasion of the larynx is complete, is rather superfluous. 
Antipyretics are out of the question unless there is a very 
high temperature depending on a complication (general diph- 
theria, pulmonary inflammations). Pilocarpine injures by 
debilitating the patient ; the cases which are really benefited 
by* it are excessively rare. Mercurials have resulted in more 
actual recoveries than any other internal treatment. The 
cyanide and iodide have been recommended. For ten years I 
have employed the bichloride in doses of a milligramme 



320 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

CsV g rani ) or more once every hour. The smallest babies 
take one-fourth or one-third of a grain daily for days in sue 
cession easily. Almost never will a stomatitis follow, and no 
gastric or intestinal irritation, provided the dilution be in the 
proportion of at least one in eight thousand. An occasional 
slight diarrhoea may require the addition of a few drops of 
paregoric. I can repeat a former statement, that never have 
I seen cases of croup getting well in such numbers, either 
without or with tracheotomy or intubation, as with mercurial 
treatment. When this treatment proves unsuccessful, intuba- 
tion or tracheotomy must be resorted to. A small, frequent, 
and intermittent pulse, aphonia, cyanosis, and marked retrac- 
tion, with every inspiration, of the supra-clavicular fossae and 
the epigastrium, are the indications for the operative proce- 
dure. I shall not here be tempted to defend the two operations ; 
I shall not even be tempted to discuss the criminality of allow- 
ing a child to suffocate without resorting to mechanical 
relief; or to compare the two operations with each other. I 
can only say that for years I have not seen a case in which 
intubation would not take the place of tracheotomy, and have 
therefore not performed the latter. Intubation has come to 
stay ; it is not one of the many temporary devices which 
have been brought out to be instantly forgotten. In most 
cases it takes the place of tracheotomy ; in none does it make 
it impossible when required in the opinion of the operator. 
The latter operation may be preferred or become necessary for 
the purpose of getting at the trachea and bronchi for the me- 
chanical removal of membrane and other local treatment, rare 
though the cases be in which such procedures are attended 
with success. 

Neurotic affections of the larynx of infants (and children) 
are quite frequent, particularly spasm of the glottis, under the 
influence of the inferior laryngeal nerve, which controls both 
the contractors and the dilators of the glottis. The treatment 



DISEASES OF THE RESPIRATORY ORGANS. 321 

is directed by its manifold causes. In neuropathic families the 
hygiene of the infant is of the utmost importance. Fresh air, 
cautious exposure to cool or cold water, and early addition of 
liquid animal food to mother's milk or to the artificial feeding 
are of importance. Rhachitis, being the most frequent cause 
of laryngismus stridulus (p. 103), requires early attention; 
digestive disorders must be corrected, and the general irrita- 
bility relieved by bromides or camphor. Monobromate of 
camphor may be given for weeks in daily doses of from one 
to three grains. Emotional disturbances must be avoided. 
The attacks (some beginning with apncea, mainly those of 
laryngismus stridulus) must be watched, the baby taken up so 
as to ease the larynx, the head raised, the tongue (if aspirated 
and doubled up) drawn forward, the throat tickled, water 
dashed into the face, and chloroform inhaled if the local spasm 
be followed by a general convulsion. 

Paralysis of the glottis is not so frequent ; in the infant quite 
rare, and very rarely congenital. Diphtheria, hysteria, and cere- 
bral diseases may give rise to unilateral or bilateral paralysis, 
anaemia may create a predisposition, glandular swellings prove 
a proximate cause. Complete paralysis depending on that of 
both posterior muscles produces a very severe dyspnoea, which 
is relieved duriug expiration and cannot be tolerated long. 
Intubation or tracheotomy may be demanded for immediate 
aid. Otherwise, attention to the predisposing causes, reduc- 
tion or removal of glands, and mainly the systematic applica- 
tion of the interrupted current through the breadth of the 
larynx will offer relief and gradual, sometimes rapid, re- 
covery. 

Neoplasms of the infant's or child's larynx are by no means 
rare. Many of them are congenital ; mostly so the numerous 
papillomata. Fibromata and enchondromata are also met 
with, and epithelioma has been observed. Sometimes they 
develop their first symptoms after an incidental inflammatory 

21 



322 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

affection. The rules for their removal are about the same 
as in the adult, only the latter are more amenable to opera- 
tions through the mouth. Indeed, none but older children can 
be thus treated, and in exceptional cases only. Laryngotomy is 
performed with or without previous tracheotomy, according to 
surgical rules, exactly as for the extraction of foreign bodies. 
There is one danger more urgent in infants and children 
than in adults ; that is hemorrhage, slight or copious. Blood 
flowing down into the narrow air-passages, even in small 
quantities, is liable to result in lobular pneumonias of a dan- 
gerous character. In order to facilitate the exit of a foreign 
body from the trachea or the bronchi after tracheotomy, it is 
best not to introduce a tube, except temporarily. The trachea 
may then be sewed to the integuments, or may be kept open 
by hooks joined by an elastic band, according to A. Caille. 

Congenital stricture of either the larynx or the trachea (rare, 
fortunately) may be mistaken for laryngeal tumor.* 

Diseases of the thyroid gland are not often observed in 
infancy and childhood ; still, even carcinoma and tubercu- 
losis have been noticed. Syphilitic gummata have been found, 
and would, if diagnosticated, demand specific treatment. 
Atrophy with myxoedema has been reported in a girl of twelve 
years ; its treatment consists in the administration of thyroid 
gland. Inflammation has been known to follow trauma and in- 
fectious or common catarrh of the nose and naso-pharynx. The 
treatment should consist of local applications of ice, hydrothera- 
peutic measures in general, saline purgatives, irrigations (both 
cleansing and antiseptic) of the nares and pharynx, and perhaps 
iodine both internally and externally during slow absorption. 
Goitre — struma — is mostly met with in the lateral lobes, and 
therefore is not liable to annoy respiration until it becomes 

* The contiguity of the thyroid and thymus glands will explain their 
being treated of at this place. 



DISEASES OF THE RESPIRATORY ORGANS. 323 

very large ; should it do so, it compresses, particularly when 
behind the sternum, the trachea, vessels, and nerves. The 
usual forms found in the adult (lymphatic, cystic, even colloid 
and fibrous) are observed. When congenital, it is apt to be 
absorbed ; the age of puberty also predisposes to spontaneous 
decrease. Most cases presented were in children from seven 
to ten years old. An occasional pulsation is not, of itself, 
pathognomonic of Graves's disease. An epidemic — infectious 
and contagious — form of goitre has been observed in schools, 
but was only a temporary ailment. Tincture of iodine, strong 
or modified, may be applied once every few days, or iodide of 
potassium in glycerin (1 : 2-8), or a potassium iodide oint- 
ment with lanolin (1 : 4-10) may be rubbed in several times 
daily. Potassium iodide may be given in doses of from five 
to fifteen grains daily. "With iodide of potassium injections 
into the tissue of the enlarged gland I have had no experience. 
The cystic form requires puncture with injection of Lugol's 
solution ; if the secondary swelling be too large and annoying, 
ice should be applied. Or the cyst, or cysts, may be incised and 
tamponed with aseptic gauze. If extirpation be preferred, 
it must not be total, because of the consecutive occurrence of 
cachexia strumipriva, tetany, and myxoedema. 

Diseases of the thymus gland are not yet amenable to treat- 
ment. Inflammations, abscesses, syphilis, tuberculosis, sar- 
coma, lymphadenoma, and carcinoma have been observed. Its 
physiological dignity for the foetus and young infant is cer- 
tainly great. Nearly forty years ago Friedleben proved that it 
cannot be done without, simultaneously with the spleen. It is 
largest (normally) from the third to the twentieth month ; about 
the ninth month it was found, in abnormally large cases, 1.5-2 
centimetres in thickness. As the distance between the manu- 
brium sterni and the vertebral column is but two centimetres 
about the eighth month of life, the slightest increase of an 
enlarged thymus through disturbed circulation, by crying or 



324 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

otherwise, may prove suddenly fatal. Such cases have oc- 
curred, though laryngismus stridulus does not, in the vast 
majority of cases, depend on the condition of the thymus (p. 
103). It has been found persistent in many (all ?) cases of 
acromegaly and local gigantic growth. 

Bronchial catarrh, bronchitis, in all its localizations, from 
the windpipes of large size down to the capillaries, requires 
an equable temperature of about 70° F., moist air, and rest 
in bed, though there may be no fever except a slight one 
towards evening. Plenty of water, — no ice, — preferably alka- 
line mineral waters, must be given ; older children may be 
prevailed upon to take gum-arabic water, flaxseed tea, or 
other glutinous decoctions which relieve the accompanying 
pharyngeal irritation. Mitigated mustard-plasters (mustard 
1, flour 4 to 8) or embrocations of turpentine are adminis- 
tered to advantage. Underclothing must be changed when 
moist with perspiration. A cotton- batting wrapper round the 
chest (the sheet spread out and two arm-holes cut into it) acts 
favorably both by keeping up a uniform temperature and by 
gently irritating the surface. As a rule, it acts better than 
warm poultices, which are liable to moisten the clothing and 
bedding, and thus add discomfort and the danger of a new 
attack. Where, however, the surface is dry, they may be 
applied, or, better still, in most cases, a cool sheet well wrung 
out of water, wrapped round the chest and changed every 
hour or half-hour after it has got hot. Bicarbonate of sodium 
from ten to fifty grains daily, according to age, and an equiv- 
alent of a grain of ipecac distributed over the day, or (and) ten 
or fifteen grains of ammonium chloride with extract of licorice 
in repeated doses during a day when expectoration is viscid and 
requires liquefying, will answer in most cases. Apomorphia 
(gr. y^-q) every two or three hours will act as an expectorant, 
so will terpine hydrate in frequent doses of gr. J-J, particu- 
larly in chronic catarrh. Complication with asthma and in- 



DISEASES OF THE RESPIRATORY ORGANS. 325 

sufficient expectoration is benefited by iodide of potassium in 
daily doses of gr. iv-xv. Insufficient expectoration with gen- 
eral debility demands the carbonate of ammonium (gr. J-l) 
every half-hour or at louger intervals, aq. camphor (one-half 
to one teaspoonful) often, or camphor (gr. J-i) every half- 
hour to every two hours. The German preparation of liquor 
ammon. anisatus has been introduced into the Formulary of 
the American Pharmaceutical Association ; from two to six 
doses may be taken every hour or two hours. Accumulation 
of mucus in the bronchial tubes, with inability to expecto- 
rate and danger of suffocation, may demand an emetic, and 
asphyxia cold affusion and raising the infant and carrying 
him about : frequent change of position is advisable in every 
severe case. When, in bad cases of capillary bronchitis, cyano- 
sis is on the increase, and the voice has not been heard for 
some time, it is absolutely necessary to make the baby cry. 
Slapping with a wet handkerchief, swinging, or closing the 
nares for a few moments, and all the means recommended for 
the asphyxia of the newly-born, are demanded. The inter- 
rupted electric current may be used with the rules and restric- 
tions recommended above (p. 42). Cough, when irritating 
and harassing, requires narcotics. Small doses of an opiate at 
regular intervals, or (and) a larger one at bedtime, or repeated 
doses of extr. hyoscyam. (gr. i-iss altogether) through the 
day, and an opiate for the night, act very beneficially. 

The chronic form of bronchial catarrh demands similar 
medication. Preventive measures are the habitual use of cool 
or cold water and the treatment of such constitutional disorders 
— for instance, rhachitis — as are known to create a predispo- 
sition. Terpine hydrate, and terebene in ten- or twenty-drop 
daily doses will act well. Chloride of ammonium may be evap- 
orated on a hot stove or tin and inhaled. Turpentine inhaled 
with steam or spread on sponges or towels is also useful. The 
pneumatic treatment (inhalation of compressed air) has been 



326 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

recommended again by Biedert. The frequent complication 
with pharyngeal catarrh demands the local treatment of the 
fauces ; a mild solution of nitrate of silver (1 : 500) may be 
used as a spray. When tuberculization is feared, the pro- 
tracted use of cod-liver oil, guaiacol several times daily, in 
drop or two-drop doses, and creosote, together with a change 
of climate, preferably moderate altitudes, are indicated. 

Fibrinous bronchitis is by no means so rare as it was formerly 
reputed to be. Indeed, during epidemics of diphtheria it is 
not uncommon. Still, the pseud o- membranes found in the 
bronchi are not always of the same nature. While some are 
diphtheritic, others consist of dry and coagulated mucus re- 
sembling the membranes of " enteritis menibrauosa." In ac- 
cordance with this difference of the prevailing condition, a 
case may last days or months. Antipyretics are still less in- 
dicated than in the common forms of bronchitis. Inhalations 
of steam, frequently repeated or kept up constantly in urgent 
cases, inhalations of turpentine with or without steam, of 
chloride of ammonium, often repeated, and fumigations through 
one or two days of from five to fifteen grains of calomel every 
hour or every few hours, under a tent, will act well. The in- 
ternal use of iodide of potassium in daily doses of from ten 
to fifty grains, and in cases of undoubted diphtheria, of the 
bichloride of mercury as required in diphtheritic laryngitis 
(p. 319), are indicated and useful. 

Bronchial catarrh, croup, and some forms of pneumonia are 
proximate causes of a collapse of pulmonary tissue, atelectasis, 
the congenital variety of which has been treated of before (p. 44). 
The predisposing causes are general atrophy with its muscular 
debility, and rhachitis through its narrowing the shape of the 
thorax. In this condition, replete as it is with urgent danger, 
the baby must be carried about, the posture in bed must be 
changed frequently, he must be made to cry, electricity must 
be used, and, besides an occasional emetic, stimulants such as 



DISEASES OF THE EESPIRATORY ORGANS. 327 

alcohol, camphor, ammonium carbonate, and musk should be 
employed frequently and copiously. 

The epidemic bronchitis, influenza, can be prevented only 
by avoiding contagion, which is even more difficult than it is 
to escape measles. Its' treatment depends a great deal on the 
variety ; gastric and intestinal symptoms require early attention, 
for nervous exhaustion is imminent in every case, and many 
patients suffer more seriously from the sequelae than from the 
original attack. Still, antipyretics cannot always be avoided. 
Phenacetin, antipyrin, and salicylate of sodium may be thus 
employed, particularly when muscular pain is one of the 
prominent complaints. Quinia also finds its ready indication. 
Opiates are often required, either in small and frequent doses 
or in a single larger dose to secure sleep. Inhalations of 
steam, two per cent, of carbolic acid having been added to the 
water, have been highly recommended, but whatever adds to 
the bronchial irritation and produces cough must be avoided. 
Rest in bed is required long after apparent recovery, for ner- 
vous symptoms are liable to appear during convalescence. 

The nature and symptoms of asthma do not differ from 
those of the same affection in adults ; nor does the treat- 
ment. Peribronchitis, emphysema, and nasal reflexes are the 
main causes, and must be attended to. In the latter class 
of cases brushing the mucous membranes of the nose and 
pharynx with a cocaine solution of from two to ten per cent., 
or the use of cocaine spray, may, in appropriate cases, relieve 
an attack ; the cauterization (actual) of the hypertrophied 
tissue and the removal of a polypus may occasionally be the 
only things required for an actual cure. Unfortunately, this 
class of cases is not so numerous as it was believed to be a 
number of years ago. Those depending on peribronchitis and 
emphysema are more frequent. In them the protracted use 
of three daily doses of from two to five grains of potassium 
iodide, together with a sufficient bedtime dose of chloral or 



328 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

of an opiate to meet the night attack, will have favorable re- 
sults. Tincture of lobelia, two or three drachms, fluid extract 
of quebracho or of grindelia, one drachm daily, will often 
have a beneficial effect in high degrees of dyspnoea. The in- 
halation of stramonium, of nitrate of potassium paper, or of 
pyridin vapors is often resorted to ; unfortunately, with so 
little permanent result as to give any number of proprietary 
medicines and nostrums a large field of activity. 

The periodic night cough, described as a special variety in 
some of the books, is either a mild attack of asthma or is 
pharyngeal or tubercular ; most pharyngeal coughs, however, 
are met with in the morning, after waking up. These noc- 
turnal attacks may be obviated by a drink of alkaline water at 
bedtime, to be repeated at every waking up, and by a dose of a 
bromide, or of chloral, or of au opiate at bedtime. Quinia 
is useless. 

Emphysema of the infant lungs is often overcome by the 
elasticity of the pulmonary tissue, and therefore its prognosis, 
no matter whether produced by forced inspiration (in pneu- 
monia) or by forced expiration (severe attacks of coughing), 
or even that resulting from ill nutrition of the alveoli, is 
not so bad as mostly in adults. Its treatment is that of 
chronic catarrh, and by gymnastic exercise of the respiratory 
muscles and general roboration. Besides, forcible expiration 
ought to be practised extensively; during expiration the 
chest wall ought to be well compressed. Snuff should be used 
half a dozen times daily, and copious sneezing procured. 
Expiration into the diluted air of one of the many pneumatic 
apparatuses is also recommended. 

Pneumonia. — There are three anatomical varieties of pneu- 
monia in infancy and childhood : the catarrhal or lobular, the 
fibrinous or lobar, and the interstitial. Nearly two-thirds of 
the cases belong to the first, one- third to the second, and a 
limited number to the third class. Not one of them, how- 



DISEASES OF THE RESPIRATORY ORGANS. 329 

ever, is always found pure and uncomplicated. Indeed, com- 
plications of the lobular with the lobar, of either of them with 
the interstitial, and possibly of each of the three with pleu- 
risy, are quite numerous. The lobular form is almost always, 
the lobar quite frequently, preceded by bronchial catarrh, 
which has its well-understood sources in exposure, sudden 
changes of temperature, local irritation by foreign bodies, 
rhachitical or tubercular mediastinal and bronchial glands, 
measles, typhoid fever, hooping-cough, etc. Thus, the prevent- 
ive treatment of pneumonia has its positive and distinct indica- 
tions. Nasal catarrh is never so slight as not, possibly, to en- 
danger the lungs. Ehachitis, glandular tuberculosis, measles, 
and hooping-cough must not be left alone to find their slow 
road to their legitimate termination for better or for worse. 
Every child, while well, should be armed against the results 
of exposure by regular invigorating ablutions and frictions 
with cold water, and when exposure has taken place and the 
consequent fever made its appearance, a warm bath, acetate 
of ammonia, camphorated tincture of opium, tincture of 
aconite, hot drinks, salicylate of sodium, or another one of 
the antipyretics and diaphoretics, with uniform temperature 
and rest in bed, may be the means of preventing pneu- 
monia. 

Acute lobular pneumonia is less a systemic disease than is the 
lobar form ; its direct and immediate influence on the nervous 
and muscular, inclusive of the cardiac, systems is less marked ; 
it is not so frequently complicated with pleurisy. Thus, there 
is less danger at first in lobular pneumonia ; there is more at a 
later period, because its duration is liable to be so long as to 
make the prognosis uncertain. The danger may come from 
the heart, but it mainly lies in suffocation, which depends less 
on the extent of inflammatory exudation than on collateral 
congestion and oedema. 

Interstitial pneumonia runs the most protracted course. 



330 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

Fever is liable to be high and prolonged over weeks and 
months; recovery is but rarely complete, induration and re- 
traction of the pulmonary tissue, with bronchiectasis, being 
quite common. 

Thus, it becomes evident that no uniform course of treat- 
ment can be dictated either for all forms of pneumonia or for 
all cases. The former are several, the latter are individual. 
After all, the patient is to be treated, and not the Greek 
name of his disease. Still, there are certain rules which 
ought to be enforced in every case. 

Insist upon absolute rest of body and mind, exclude vis- 
itors, light, and noise. 

Keep the temperature of the room between 68° and 72° F. 
and the air moderately moist. 

Let the patient select his own position. 

Isolate a lobar case. 

Give liquid food, and plenty of water, or lemonade, or hy- 
drochloric acid in water. 

Relieve the circulation from accessory incumbrances ; a dose 
of calomel will facilitate the action of the diaphragm by 
emptying the bowels and relieving flatulency, and will di- 
minish the tension of the arteries. 

The main dangers in acute pneumonia are : high tempera- 
ture, heart-failure, and suffocation, which may result from the 
condition either of the lungs, or of the right heart (the left 
not being at fault so often as it is in the adult), or of both. 

What degrees of temperature may be allowed to last, and 
what are to be interfered with? Is it 103°, 104°, 105°? 
It is well understood that persistent high temperature disinte- 
grates tissue, but this effect is not equally attained in all 
cases. Many a child bears 104° quite easily, while others 
succumb to 103°. Moreover, a temperature which is badly 
borne the first day or two appears to be an indifferent matter 
afterwards. Thus, antipyretic treatment may be indicated at 



DISEASES OF THE RESPIRATORY ORGANS. 331 

first and be no longer required later, particularly in those 
cases which exhibit a decided morning remission ; for it is 
mainly a persistent height of temperature that is injurious, 
not its occasional, though regular, rise. Thus it is that, for in- 
stance, relapsing fever, with its enormous temperatures but 
complete intermissions, has but a small mortality. 

The habit of depressing temperatures in all cases which ex- 
hibit a temperature of 103°, or thereabouts, is bad ; it is not 
the temperature that is injurious, but the absence or insuffi- 
ciency of resistance that the tissues offer to its action. To 
lower temperature we have a number of remedies. The latest 
additions to our antipyretic treasures are very well known and 
too universally employed. Phenacetin, antipyrin, and ace- 
tanilid have more frequently lowered temperatures than they 
have saved lives. Their doses, uses, and dangers are well un- 
derstood by all practitioners. Wherever they are found in- 
competent, their combination with quinine has proved more 
effective. The latter, by itself, is, however, no longer the sine 
qua non which it was formerly believed to be. In all cases 
with marked remission it acts well, but it is during the re- 
mission ouly that it should be given. Half a gramme to a 
gramme may be thus employed. It may be used internally 
or hypodermically. Now and then injections into the rectum, 
or suppositories, are required or advisable when the stomach 
cannot be relied upon. The preparation to be used in the 
rectum must be one of those which are most soluble : the bi- 
sulphate, muriate, bromide, or carbamide. No acid should 
enter into the solution ; large quantities of glycerin are ob- 
jectionable. The rectal dose should be at least fifty per cent, 
larger than that employed internally. 

The internal administration is often hindered by the taste 
of the drug. Thirty parts of the compound known as elixir 
simplex cover the taste of one part of the sulphate, provided 
the mixture is made with each dose and not kept ready ; thus, 



332 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

the drug should be prescribed in the form of a powder, to be 
mixed with the elixir when needed. Preparations of coffee, 
either infusion or syrup, hide the taste of quinia quite well ; 
so does, to a certain extent, licorice extract ; so does choco- 
late. The neutral tannate of quinine is tasteless, but the dose 
must be two and a half times larger than that of the sulphate. 
The muriate agrees best with an irritable stomach, the bromide 
with an impressible brain. The latter is slower in producing 
cinchonism. The best preparation for hypodermic injections 
is the carbamide of quinia, which dissolves easily in five parts 
of water, remains in solution, and yields no deposits of quinia 
in the subcutaneous tissue. I have employed it for at least a 
dozen years, and observed serious local irritation in but one 
instance. 

The best antipyretic is cold. Its use has been praised and 
condemned, as everything deserves to be that is employed 
either properly or thoughtlessly. Most cases will do quite 
well with sponging, or with friction by means of wet and cold 
towels. The latter plan acts both as a refrigerant and a stimu- 
lant. Cold bathing was once eulogized immensely, then 
abhorred and warm bathing substituted. The rationale of 
cold bathing is the cooling of the surface (that is, of four- 
teen square feet in the adult ; more than proportionately in the 
young) with its immense surface circulation. So long as this 
circulation continues active, new blood will come to the surface 
every moment, and the w r hole body is thereby cooled. When 
it is no longer active, the heart weak, the extremities cold, 
cold bathing is dangerous. The rule I have prescribed many 
years ago was this : no cold bath for cold extremities ; no 
more cold bathing when once, after it, the extremities remain 
cold or cool. In these cases after a cold bath the surface be- 
comes colder than before, it is true ; the interior, however, 
warmer than it was. I have reported the case of a little child, 
twenty years ago, who was the first to teach me that lesson. 



DISEASES OF THE RESPIRATORY ORGANS. 333 

A few cold baths had reduced his temperature and his ten- 
dency to convulsions. Then another seemed to be indicated. 
It appeared to render the required service, but the baby be- 
came convulsed. The temperature in the rectum had risen 
from 104J° to 106°. A hot bath, instantly given, restored 
the external circulation, and ten minutes afterwards the rectal 
temperature was below 102°. 

A great promoter of circulation, and thereby of radiation 
from the skin, is surface warmth, and particularly warm ex- 
tremities. Warming-paus ought always to be applied to the feet 
and legs when cold is to be employed. In place of cold bathing, 
I have mostly employed cold packing from the chest down 
to the thighs, the arms usually outside the pack. Nothing is 
easier than to wrap a baby up in a single wet towel, which is 
covered by a small blanket ; in an urgent case it should be re- 
placed by another one (spread out beforehand) every two or five 
minutes. From twenty to forty minutes' packing will reduce 
the temperature from 106° to 101°, and below. In many 
instances the rapidly falling temperature demands artificial 
warming immediately afterwards. When the frequent chang- 
ing of the pack is undesirable, it may be allowed to remain, 
and frequently cooled by rubbing a piece of ice over the whole 
surface. If water collect under the patient, it can easily be 
absorbed by towels or sponges. A temperature of 108° in a 
baby of four months, suffering from pneumonia, was reduced 
to 104° in twenty-five minutes ; after that it sunk rapidly to 
94 J°, and artificial warming of the surface was required. 

From what has been said it is evident that very feeble 
and anaemic babies do not tolerate cold, though their tempera- 
ture be ever so high ; in such cases a warm bath, or tepid 
packs either with water or alcohol and water, or a warm bath 
gradually and gently cooled down while the little body is con- 
stantly being rubbed, should take the place of the cold pack ; 
or cold applications to a part, perhaps the anterior aspect of the 



334 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

chest, are found to suffice. They both reduce temperature and 
relieve local pain. In many cases a light ice bag over the 
heart acts both as a refrigerant and a stimulus to the organ at 
the same time. 

The acceptance of these views I urgently recommend to 
those to whom they are in part new. Before and after 1870, 
when I recommended (New York Medical Record) cold water 
in typhoid fever, scarlatina, variola, ophthalmia, diphtheritic 
conjunctivitis, diphtheria, lobar and other pneumonia, heart- 
disease, local inflammations, phlegmon, synovitis, and peri- 
tonitis, I had ample opportunities to test what I am here ad- 
vocating. Those who want to inform themselves thoroughly 
on matters connected with this subject I refer to Dr. Simon 
Baruch's well-known book. 

The heart furnishes urgent indications for treatment in 
many cases of pneumonia. When in a healthy condition, its 
innervation and force are not easily disturbed ; still, every pul- 
monary disease taxes its powers. Lobar pneumonia requires 
cardiac stimulation at an earlier period than the lobular kind. 
There is none, however, but demands it at some time or other, 
That being the case, I earnestly advise not to wait, for heart- 
failure is more easily prevented than cured. Be our treatment 
ever so expectant, it must not be indolent and indifferent. In 
order to correct the faulty pulmonary circulation the heart 
must be stimulated at an early period. But how? 

Alcoholic beverages are employed for this purpose by many, 
for alcohol is certainly a cardiac stimulant ; it is believed by 
many to lower arterial tension, — a function which is doubtful, 
at least in pure inflammatory disorders ; moreover, it is believed 
to be an article of food. In the small quantities in which it 
is administered it certainly is not. Much of it is eliminated 
unaltered through the lungs, which are thus burdened with 
that additional labor while in a condition of exhaustion and 
incompetency. Besides, kidney complications, which are not 



DISEASES OF THE RESPIRATORY ORGANS. 335 

rare in pneumonia, and brain affections, which are frequent, 
particularly in small children, contraindicate the use of alco- 
hol. I dare say that the pneumonia of a fairly developed 
infant or child contraindicates rather than demands the admin- 
istration of alcohol at an early period of the disease. Later 
on the conditions change, and alcohol may be required in 
large doses, always, however, much diluted. A recent writer 
has indeed proclaimed that the doses of alcohol given by 
medical men in the diseases of children are in direct propor- 
tion to their ignorance, but epigrammatic pronunciamentos do 
not do away with the good effects of alcoholics among the 
rest of the stimulants. 

Digitalis stimulates and contracts the heart, but also the 
arteries, and thereby increases the peripheral resistance. A few 
large doses may restore the equilibrium of the faltering circula- 
tion, and should then be stopped. I have not infrequently 
given the equivalent of from one to four grains of digitalis in 
a single dose, which was repeated one or more times. This 
mode of administration insures all the coveted effect on heart 
and pulse without any irregularity, and gives both a result in a 
few hours and the indication to cease, while the usual small 
doses exhibit their action after days only. We may afterwards 
continue its use in small doses, either alone or in combination 
with strophanthus, sparteine, or caffeine, all of which have no 
such disagreeable effect on the arterial tension as digitalis ; or 
we may give them without digitalis. To give doses of tincture 
of strophanthus of less than a drop, or sparteine sulphate of 
less than one-quarter or one-eighth of a grain, every hour or 
two, is useless. Such effect as we require we have a right to de- 
mand speedily, and the doses must be large enough to enforce it. 

Whenever the peripheral circulation becomes insufficient, 
with small pulse, digitalis alone must not be continued ; it must 
be combined with nitroglycerin or sodium nitrite, the former 
in hourly or bi-hourly doses of from ^g- to jfa of a grain, the 



336 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

latter in doses of from y 1 ^ to ^, or these remedies may be given 
alone until the pulse is revived. They are principally required 
when the feebleness of the heart is mainly perceptible in the 
right ventricle. There are cases of pneumonia in which the ar- 
terial pulse is good, but the external veins large, the nails blue, 
the skin cyanotic, with great dyspnoea and pulmonary oedema, 
together with perspiration, increased cardiac dulness, enlarged 
liver, intestinal oversecretion, and albuminuria, — symptoms 
which point directly to incompetency of the right ventricle. 
In these cases the external circulation must be restored at once, 
and the nitrites will contribute to fulfilling that indication. 
Besides, local depletion by leeching will sometimes do good. 
In the adult we would open a vein ; a child of advanced age 
may also be saved in this way. Once, and once only, when I was 
younger than I am to-day and more courageous or less cowardly, 
I opened the engorged jugular vein of a young child suffo- 
cating from pneumonia. The tenement-house people for whom 
I did it thought it the proper thing and nothing else, while I 
was not quite so confident: the child got well. Cupping, both 
dry and sometimes wet, large sinapisms, and mustard baths 
will serve a good purpose. Concerning the latter method, Dr. 
L. Weber published an elaborate article some twelve years ago. 
" General mustard bathing I have now and then resorted to in 
severe inflammations of the lungs, as well as in those of the 
brain. I prepared a hot bath and threw mustard into it ad 
libitum in order to produce a very powerful derivation to the 
skin in a very few minutes, and I think it had most beneficial 
results." * It is in these cases also that the inhalation of oxygen 
(better through the nose than the mouth) and artificial respira- 
tion will contribute a great deal towards saving time and life. 
The distressing cases of catarrhal pneumonia engrafted 
upon the extensive bronchial catarrh or capillary bronchitis 

* Jacobi, in New York Medical Kecord, August 15, 1870. 



DISEASES OF THE RESPIRATORY ORGANS. 337 

of the very young will sometimes get well only after we suc- 
ceed in making them cry, together with artificial respiration, 
inviting the respiratory muscles to reflex efforts by dashing 
cold water on them, using for brief moments the interrupted 
current, etc. 

Direct stimulation of the heart may require the use of 
strychnia in small and frequent doses (a baby of one year not 
often more than a thirtieth of a grain during twenty-four 
hours), and carbonate of ammonium one-half of a grain or a 
grain in anise-seed water or in milk every half-, one, or two 
hours. In cases of urgent necessity the stimulants must be 
used subcutaneously, the sulphate of strychnia in repeated 
doses of j-^-g- grain at least, the salicylate (or benzoate) of sodium 
and caffeine in doses of from one to five grains (equivalent to 
one-half of that amount in caffeine) every one or four hours ; 
or camphor will serve the same purpose. Its solutions in 
alcohol or ether are quite painful. I always employ it in four 
or five parts of sweet almond oil ; of this I inject from six to 
twenty drops, according to indications ; very slowly, because it 
passes through a fine needle with more difficulty than does a 
watery solution. 

In connection with these remarks we are enabled to judge 
of the claims of the routine treatment with strychnine, digi- 
talin, and aconitine which was imported a few years ago. It 
is easily perceived that it finds its indications like a ready-made 
coat which fits many, but not all, and would not be worn un- 
less first tried on. But, then, a coat is not so easily believed 
to fit everybody as is a newly eulogized treatment. 

When, during hepatization and the period of incipient reso- 
lution, expectoration is insufficient, the remedy is inhalation of 
steam, with or without turpentine. The latter may be spread 
through the room by means of large sponges, or on towels which 
are soaked with it, or it may be evaporated on boili ng water. The 
easiest way is to fill the whole room with the vapor. Inhalers 

22 



338 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

are insufficient and annoying. Give camphor, aqua camphorse 
in teaspoon doses or more, or one-quarter- to one-grain doses in 
diluted mucilage, or benzoic acid powders in the same doses, 
or ammonium carbonate. Ipecac may derange the stomach, 
senega is either an adjuvant or a placebo. Drinking of plenty 
of water, mainly alkaline waters, — Seltzer, Vichy, Poland, — 
also doses of bicarbonate of sodium or iodide of potassium, 
will increase and liquefy the bronchial secretion. Ammonium 
chloride is of but little use in hepatization ; but evaporated 
in amounts of ten or twenty grains every few hours on a hot 
stove or over a flame, it fills the room with a white cloud 
which greatly stimulates the bronchi. Warm poultices will 
serve the same purpose. Their place is during hepatization 
for the purpose of aiding absorption, not in the first stage of 
pneumonia. When nursing is insufficient, and there is danger 
of wetting the clothing and bedding, it is best to substitute for 
them a cotton -wadding jacket, covered or not with oil silk or, 
better, flannel, which protects against exposure and keeps up 
a uniform temperature of the skin. 

Pleural pain is relieved by gently strapping the chest, when 
tolerated, — it mostly is, — by sinapisms, which must be kept on 
a few minutes only and repeated from time to time ; warm 
poultices ; a few doses of sodium salicylate or phenacetin ; in 
urgent cases by a subcutaneous injection of morphia. Vesica- 
tories are injurious ; they chafe, irritate, annoy. Their only 
— rare — indication is in the long persistence of hepatization, 
with or without chronic pleurisy. 

Irritating, hacking cough demands small doses of opium. 
Much of this cough is pharyngeal, and is relieved by frequent 
drinking of small quantities of water. Sleeplessness and great 
general irritation demand a dose of opium for the night. A 
sleep of an hour or two affords great relief to the cough and 
to all the symptoms. As a general rule, however, the habit 
of giving opium in the first stage of pneumonia is a bad one. 



DISEASES OF THE RESPIRATORY ORGANS. 339 

The bad odor of complicating gangrene demands inhala- 
tions of turpentine, eucalyptol, or carbolic acid ; the presence 
of abscesses in the lung, surgical interference, unless there be 
a spontaneous rupture through a bronchus. Most abscesses 
are within reach of the knife and actual cautery, for generally 
there is a sufficient amount of pleural adhesion to render 
access devoid of all danger. 

Complication with malaria, which is rare, requires quinine ; 
intermittent pneumonia, which is also uncommon, quinine and 
ergot ; complication with nephritis, the avoidance of digitalis 
and alcohol and the substitution therefor of sparteine, camphor, 
and nitro-glycerin ; with atelectasis, the stronger stimulants, 
and artificial respiration by the different methods — make them 
cry ; with cerebral disease, while acute, ice and purgatives and 
bromides ; when chronic, iodide of potassium. 

Hypostasis and hypostatic pneumonia, so common in in- 
fectious diseases and in conditions of great debility, require 
frequent changing of position from one side to the other and 
the early administration of stimulants in large doses, together 
with friction of the entire surface with cold or hot water, or 
with alcohol and water. The most powerful of all internal 
stimulants — Siberian musk — should be given frequently, — 
viz., every half- to one or two hours, — in doses of from one- 
half to two grains, until from six to fifteen grains have been 
taken in the course of half a day. 

Interstitial pneumonia is treated on the general principles 
laid down before. Later, iodide of potassium in sufficient 
doses, a mild tincture of iodine externally, and an occasional 
vesicatory. When it has become chronic, digitalis may be 
given for months in small doses to keep up both a sufficient 
circulation through the indurated lung and a competent nu- 
trition of the heart muscle, and iodide of potassium alter- 
nating with iodide of iron. Persistent and careful pulmonary 
gymnastics must be continued for years. 



340 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

Pulmonary oedema requires the causal treatment of its origin, 
which can be traced to cardiac, pulmonary, or renal disease. 
Urgent cases — for the disease may prove fatal in a short time — 
require dry cupping, now and then the emptying of the lungs 
by an emetic (apomorphia subcutaneously when vitality is low 
and the expelling muscles are unable to act), and stimulation 
of the excreting organs and of the heart. A powerful purga- 
tive — calomel, croton oil, or elaterium — is an active derivant. 
Digitalis in large doses (a few minims of the fluid extract at 
once) will stimulate the heart. The salicylate or benzoate of 
sodio- caffeine in subcutaneous injections, one to five grains, 
repeated five or six times at intervals of fifteen minutes, acts 
beautifully. Acetate of lead stops oversecretion in a good 
many instances. Pilocarpine (gr. fa to jr) subcutaneously has 
relieved, and saved, many a case resulting from renal disease. 

Pulmonary hemorrhage is not frequent, for tuberculosis of 
the young lung produces hepatization and vascular obstruction 
rather than cavities ; and though hooping-cough gives rise 
to hemorrhages, they are tracheal and bronchial rather than 
pulmonary. Cardiac diseases may lead to venous obstruction 
and thereby to hemorrhages. Digitalis, lead, alum, ergot, 
narcotics, and ice temporarily to the chest, with a hot (mustard) 
bath of the lower half of the body, as well as absolute physical 
and mental rest, are indicated. 

Infardus, with its sudden onset and vehement dyspnoea 
(sometimes chill), is the result of embolism, in the newly- 
born, from the umbilical vein or the ductus arteriosus ; later, 
from a marantic thrombosis of the sinus, the renal, femoral, 
or portal vein, or from caries of the petrous or some other 
bone; from valvular disease, from an infectious malady, or 
from an extensive burn. The causal indications must be 
obeyed, if possible. Ice applications to the affected part, 
opiates and digitalis, and stimulants when required, symp- 
tomatic treatment afterwards (antipyretics). 



DISEASES OF THE RESPIRATORY ORGANS. 341 

Some of the cases are followed by gangrene. This condi- 
tion, however, generally results from the presence of foreign 
bodies, from acute infectious diseases, — diphtheria, measles, 
noma, typhoid, — or from (lobular mostly) pneumonia. A few 
cases are also on record as having resulted from careless pneu- 
matic treatment. Mineral acids largely diluted with water, as 
also quinia and lead, have been copiously used. Besides stim- 
ulants given to the required extent, I have relied mainly on 
inhalations of turpentine, either from a paper bag in which a 
sponge has been kept soaked, or from a kettle Avith boiling 
water, or of terebene ; internally, of terebene, from twenty to 
fifty drops daily, or creosote a few drops daily. (See p. 339.) 

Such pseudoplasms as have been or may be observed in the 
young lungs demand treatmeut on general principles. Card- 
noma has been noticed a few times, also in the mediastinum. 
Sarcoma is more common, also in the pleura. The treatment 
should consist in increasing doses of arsenic, and in the injec- 
tion, according to Coley, of the toxin of the coccus erysipela- 
tos and bacillus prodigiosus. Echinococcus of the lungs and 
pleura (fluid without albumen and sodium chloride, and with 
scolices) demands puncture and the injection of Lugol's iodine 
solution. Actinomycosis has been reported by Soltmann ; the 
case occurred in the posterior mediastinum of a boy of six years. 

Hernia of the lungs has been observed below the clavicle and 
on the back. The soft elastic tumor changes its size with res- 
piration. In such cases the lung is either normal or emphy- 
sematous. The cough disappears on the application of proper 
bandages. Deformities of the chest wall, with or without a 
defect in bones or muscles, particularly the funnel chest, in 
which the lower part of the sternum is so drawn in as to 
almost touch the vertebral column, can never be removed, but 
the consecutive contraction of the intra- thoracic space can be 
partially counterbalanced by systematic gymnastics and func- 
tional improvement of the lungs. 



342 THERAPEUTICS OF INFANCY AKD CHILDHOOD. 

In close connection with the congestive and inflammatory 
diseases of the thoracic organs are many changes in the bron- 
chial and mediastinal glands which can more easily be pre- 
vented than cured. A protracted catarrh of the bronchi re- 
sults in glandular hyperemia and hyperplasia ; a nasal catarrh 
of the newly-born and the nursling descends rapidly with the 
same effect, or the consecutive glandular tumefactions of the 
submental and submaxillary regions implicate the adjoining 
tiers of lymph bodies ; rhachitis, scrofula, and tuberculosis are 
also causes of bronchial and mediastinal adenitis. Pressure 
on veins and nerves, also on the trachea ; attacks of coughing 
without crowing inspiration ; fremitus, feeble or increased ; 
respiration, increased and bronchial, or feeble; dulness over 
the sternum down to the second rib, but not extending to the 
exterior margin of the lungs ; dulness posteriorly about the 
hilus of the lungs, more marked to the left than to the right 
(location of thoracic duct on the left), are among the principal 
symptoms. Fever, if present, depends on complications or on 
absorption from the glands while undergoing changes. Anti- 
rhachitical, antiscrofulous, and antitubercular treatment are 
the indications. Mercurial ointment, iodide of potassium oint- 
ment, inunction of green soap, iodide of potassium internally, 
iodide of iron, increasing doses of arsenic, ice externally if 
there be any local pain, and the treatment of sequelae or com- 
plications (catarrh, lobular pneumonia, dyspnoea, protracted 
fever) will be demanded, but will not always prove successful. 

Pleurisy is of frequent occurrence during the first decade 
of life ; empyema is, indeed, more common during infancy 
and childhood than in advanced age. The majority of cases 
of pleurisy which occur in the newly-born are of pysemic 
origin, and depend mostly on umbilical phlebitis ; still, cases 
with serous and the usual forms of purulent secretion are not 
uncommon in the very young. Pleuritis may be the direct 
result of exposure (" cold"), of broncho- and fibrinous pneu- 



DISEASES OF THE RESPIRATORY ORGANS. 343 

monia, or of pericarditis and peritonitis. It frequently accom- 
panies pulmonary tuberculosis, diphtheria, acute rheumatism, 
and eruptive fevers. Thus, there is but rarely a causal indi- 
cation for treatment ; prevention is best secured by giving the 
utmost care to the management of those diseases which cause 
its outbreak. Its symptoms are often deceptive, for even pain 
is not always present, though it is one of the most frequent 
symptoms. The pain is sometimes quite local ; at other times, 
however, it extends over a large surface. Its locality does not 
always correspond with the seat of the pleuritis. The extension 
of the peripherous ramifications of the intercostal nerves is so 
great that the children often complain bitterly of epigastric 
pain down to the umbilicus on the affected side. The disease 
requires absolute rest and immobilization of the chest. Broad 
strips of adhesive plaster, which irritate the surface and render 
local applications difficult, I have discarded long ago. A broad 
bandage or a moderate-sized towel fastened round the chest 
with safety-pins is more appropriate and is well tolerated. An 
ice bladder applied to the diseased region will often render the 
best service ; it must not come in contact with the bare skin. 
Where no bandaging is required, a cloth well wrung out of cold 
water, of the size of half a square foot, more or less, or sur- 
rounding the whole chest, may be applied every fifteen or thirty 
minutes. It must be covered with rubber cloth and flannel. 
In very bad cases the pain should be relieved by a subcutaneous 
injection of morphia; its internal administration is generally use- 
less and sometimes hurtful. Local depletion by cups or leeches, 
I am glad to say, I have shunned these twenty-five years ; dry 
cupping may relieve such children as are old enough and in- 
telligent enough not to get excited and not to harm themselves 
by screaming and active resistance. Mustard plasters must 
not remain longer than a few minutes, and may be repeated 
every few hours. Warm fomentations will relieve anaemic 
and feeble children ; if possible, they ought to be avoided 



344 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

in the beginning of the disease, when the indication to limit 
congestion and secretion is paramount. A dose of calomel 
sufficient to relieve the bowels (sometimes with an opiate) and 
the use of salicylate of sodium in doses adapted to the age 
of the patient are the remedies which will bring relief. Ve- 
sicatories are still less indicated in the first stage of pleurisy 
than later on ; they irritate both the skin and the patient, 
cause sleepless nights, and add to the discomfort of the occa- 
sion, and discomfort and sleeplessness impair the prognosis. 
If there were a benefit to be derived from blistering, the 
condition of the pleura might be improved, perhaps, but the 
sick injured, probably. 

If the temperature be so high as to hurt the patient, anti- 
pyretics should be given. Probably from three to ten grains 
of quinine administered before noon will lower the afternoon 
rise. If required, a dose of phenacetin, with or without a 
moderate dose of codeia, may be given at eight or ten o'clock 
at night. 

When the fever decreases, or when the heart begins to get 
weak previously, digitalis, strophanthus, sparteine, or caffeine, 
with or without ammonium carbonate or camphor, are indi- 
cated ; no improvement, either through diaphoresis or through 
diuresis, need be expected so long as the heart remains weak. 
At the same time an acetate, or a citrate, or an iodide may be 
given. Pilocarpine, which has been recommended, is a two- 
bladed sword, and requires a stronger constitution than almost 
any baby and most children can boast of; in pleurisy there is 
no vital indication that can be fulfilled by pilocarpine to such 
advantage as may be derived from it in certain cases of acute 
pulmonary or intra-cranial oedema. Externally, at this period, 
tincture of iodine diluted with alcohol may do some little good, 
particularly in cases of " dry pleurisy." It is this form mainly 
which will be benefited by warm fomentations and the use of 
iodides. When the main indication is to absorb effusion, absti- 



DISEASES OF THE RESPIRATORY ORGANS. 345 

nence from drinking, and the use, in fair doses, of table salt, 
which increases diuresis, will be found useful. Diuretin, in 
four daily doses of from two to five grains, may stimulate the 
action of the kidneys to such an extent as to result in the ab- 
sorption of the pleural effusion ; but my own experience with 
this modern drug has not been so favorable as many of the 
eulogies contained in the journals appeared to promise. 

The indications for operative interference with the pressure 
of pleural effusions, no matter of what description, are vari- 
ous. It is demanded when the difficulties of either respira- 
tion or circulation, or both, require immediate relief. The 
latter may suffer even without the participation to a great ex- 
tent of the former. Indeed, Trousseau describes a case of fatal 
collapse due to nothing but disordered circulation. Among 
the symptoms urging the operation are intense dyspnoea, cya- 
nosis, diminution of renal secretion, anasarca and ascites, and 
a considerable dislocation of heart or liver. In many cases 
the intercostal interstices are no longer visible, either on inspi- 
ration or expiration ; they are even found bulging. Not in 
every case are the consecutive disorders proportionate to the 
amount of effusion ; indeed, this may be small compared with 
its effects when the pleurisy is complicated or secondary to a 
disease of either heart or kidneys, or both. Still, the quantity 
of fluid contained in the pleural cavity is more frequently 
underestimated than the reverse, no matter whether the healthy 
lung is pressed upward and is floating on the liquid in a com- 
pressed condition, or whether, congested or inflamed, it is 
swimming in the midst of the fluid. Thus, it is impossible to 
exactly gauge the indications of the operation according to the 
amount of exudation. Potain's claim, that when the latter 
readies the level of the clavicle the operation should be per- 
formed, is justified by the fact that the consecutive symptoms 
in most such cases must be very urgent. In such persons 
as do not subjectively complain, their indifference is mostly 



346 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

due to lack of cerebral perception, — in conditions of uncon- 
sciousness during meningitis, typhoid fever, or idiocy. When 
the dulness extends high up both anteriorly and posteriorly, 
and no absorption takes place within a few weeks, the opera- 
tion is required. The longer the compression of the lung has 
lasted the smaller will be the chances of its rei Dilation. It 
is true, however, that now and then it will re-expand after 
compression has lasted from two to three months. Another 
serious danger accompanying the pressure produced by the 
liquid is the inactivity of the blood- and lymph- vessels of the 
walls of the cavity ; for in such case total compression means 
absence of function, which is absorption. Thus, even a partial 
removal of the fluid, with partial relief to the vessels, is quite 
often the first stimulus to absorption and the commencement 
of recovery. 

In order to either make or confirm the diagnosis of exuda- 
tive pleurisy, an explorative puncture is often resorted to. 
For, in spite of a Dumber of ratiooal symptoms, the positive 
diagDosis of a pleural effusion or exudation is sometimes im- 
possible without its ocular coufirmatioD. The puncture is 
made near the upper edge of a rib to avoid the course of the in- 
tercostal artery, while the hand of the diseased side is carried 
to the opposite shoulder to widen the intercostal spaces. The 
pain of the little operation is diminished by the quickness of 
its performance ; besides, a slow introduction of the needle — 
particularly when of larger size — may peel off the pleura from 
the chest wall. In many cases of copious exudation the place 
selected, within certain limits, is a matter of indifference. The 
puncture is mostly made where there is bulging, or a high 
degree of dulness, or more or less complete absence of respira- 
tory murmur, frequently in the sixth intercostal space poste- 
riorly to the axillary line. When these spaces are narrow, or 
when the patient is restless, it is not always easy to penetrate 
them ; these are the cases in which, now and then, the inter- 



DISEASES OF THE RESPIRATORY ORGANS. 347 

costal artery has been wounded, or pain resulted from hitting 
periosteum and bone. When the point of the needle is not 
carried far enough, it may land in the chest wall or in the 
thickened pleura ; when too far, it reaches the lung ; when 
in a wrong direction, it may be fastened in the liver or in 
the spleen. In such cases the needle is liable to participate 
in the excursions produced by inspiration and expiration, and, 
when withdrawn, will carry blood instead of the contents of 
the pleural cavity. In rare cases it is possible, however, to 
exhibit the latter and still wound the lung. It has happened 
to me to extract pus from a pyothorax. On the very spot of 
the puncture the incision was made and a rib resected ; when 
the incision through the pleura was made, there was bleed- 
ing from the lung. The wound was closed with iodoform 
gauze, a new puncture was made at a different locality, pus 
was found, the rib exsected, and again there was, on incision, 
pulmonary hemorrhage, w T hich also was stopped by compres- 
sion with iodoform gauze. A third puncture and a third ex- 
cision at last led directly into the empyema ; the failures 
having been due to extensive pleural adhesions, and the de- 
ceptive results of the exploring punctures to the fact that the 
needle did not reach pus until it had perforated the adhering 
and twisted lung. 

While an absolute diagnosis cannot always be made without 
a puncture, the results of the latter are not always conclusive. 
Though there be plenty of liquid (serum, pus, blood) in the 
cavity, it may not always follow the sucking piston. The 
point of the needle may first land in the lung after passing 
through liquid ; this will enter the instrument only while the 
needle is being slowly withdrawn, provided again that it has 
not been closed by a blood-clot. Therefore, when the puncture 
is futile, the needle ought to be carefully examined as to its 
perviousness. Or the needle is too thin for the contents ; pus 
is quite often present where serum was expected ; or the needle 



348 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

is caught in thick fibrin deposits. That may happen time 
and again, and lead to serious miscalculations and mistakes. 
Or the pleurisy may be localized, with the result of giving 
rise to an encysted empyema, instead of a general pyothorax. 
Such localized empyemata are more frequently met with poste- 
riorly, and upward, than low down, where they are usually 
expected, from the fact that it is there that free pleural fluids 
are found. They are quite small sometimes, and not infre- 
quently multiple, and therefore hard to find. Puncture upon 
puncture must be made iu such cases as yield all the rational 
symptoms of pyaemia, and when no pus can be readily de- 
tected. When finally found, it is not always certain to 
come from a pleural abscess after all. It may be derived 
from a small pulmonary abscess, or from a pyopneumothorax. 
In the latter instance, however, and sometimes in the former 
also, there is often air (or gas) found mingled with the 
pus. 

There are other possibilities of mistake. The needle may 
have withdrawn serum only, and yet pus or blood may be 
present ; for in patients who have been in a recumbent- or 
semi-erect position, as usual with pleuritics, the solid constit- 
uents of blood and pus will be deposited near the diaphragm. 
Thus, a microscopical examination ought first to complete the 
diagnosis of the nature of the pleural contents. When pus has 
been found, there is an urgent indication not to procrastinate 
the radical operation, for the puncture channel may become the 
seat of pus infiltration, and possibly of pysemia. Particu- 
larly is this so when the pus is discolored and malodorous, as 
it is apt to be in cases of pyopneumothorax, or in those which 
are complicated with caries. The latter cases are apt to be at- 
tended with high temperatures (still, there are exceptions), the 
fever being either continuous or irregularly intermittent. 
Such fevers require an exploring puncture at an early date ; it 
is mostly delayed too long. Indeed, every case of uncompli- 



DISEASES OF THE RESPIRATORY ORGAKS. 349 

cated pleurisy in which a high temperature is incessant for 
four or five days, ruaiuly when complicated with much pain 
or local oedema, becomes suspicious. Even as early as the 
fourth day I have met with large amounts of pus, not only in 
infants and children, who are more apt to develop pleural sup- 
purations, but also in adults. Moderately high temperatures, 
however, do not necessarily indicate the use of the needle, for 
through periods of weeks, temperatures of 100 J° or 101° may 
persist without meaning anything but the systemic irritation 
caused by a perpetual process of absorption and elimination. 
Thus, after all, there is no positive certainty that can be con- 
veyed to the unthinking ; here it is, like everywhere in medi- 
cine, that experience comes handy, when guided by brains. 

Before the operation of puncturing is performed, the skin 
must be thoroughly washed (and disinfected) ; after the needle 
has been withdrawn, iodoform gauze or bismuth subnitrate 
powder is applied to the wound and covered with adhesive 
plaster or a bandage. If there be paiu, ice is applied. At all 
events, the chest ought to be at rest ; the patient, if possible, 
in bed ; no exercise or work permitted for a day. As a 
remedial agent a simple puncture is of no account. When 
recovery follows an exploring puncture, it is spontaneous, and 
not induced by it ; for spontaneous absorption of the pleural 
fluids, both of transudations and exudations, is quite frequent. 
That is mainly so when the liquid is serous only and not 
too excessive ; in the latter case, absorption begins only when, 
by means of an aspiration, the pressure by w T hich blood- and 
lymph-vessels are hampered has been in part relieved. Nor 
is it infrequent for hemorrhagic exudations, or even extrava- 
sations, to be absorbed after the solid constituents have been 
deposited on the surfaces of the pleurae. Even the results 
of tubercular pleurisy may disappear, just as ascites caused 
by tubercular peritonitis is apt to get well, whether or not 
tubercle-bacilli are found in the fluid. As a rule, in most 



350 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

of the cases of spontaneous recovery no microbes are present ; 
if they be found, they are mostly the short-lived cocci of 
Fraenkel. No such favorable event, however, need be looked 
for when the long-lived streptococcus and staphylococcus 
are present; still worse is the influence of proteus vulgaris 
and mirabilis of the putrid empyema. Simple encysted 
empyema, however, may finally heal without any operative 
interference, through a process of gradual inspissation and 
absorption. 

Spontaneous perforation of pyothorax, either through the 
lungs or through the chest wall, may lead to recovery ; but it 
is slow, and takes place at the expense of much time, suffer- 
ing, tissue, and usually of future health and vigor. It should 
never be wished or waited for. 

Thoracocentesis ought to be performed soon al'ter the ex- 
ploring puncture. In many cases, when a mere aspiration is 
made, the operation appears simple enough ; but it ought to 
be considered serious in all cases, as in many it is. The pa- 
tient must rest quietly and be well supported in the position 
recommended for a simple puncture, and so that respiration 
and circulation are not unduly interfered with. The needle 
must be inserted with the precautions detailed in the remarks 
I made on puncture ; if it be caught by a fibrin clot, the 
latter may be detected by a probe introduced through the 
needle, but a second insertion may be required to obtain the 
end, probably anteriorly and superiorly to the first one. As- 
piration aloue will not cure empyema, except in small chil- 
dren, whose ribs are flexible and whose chests can be com- 
pressed more readily so as to approximate and adjust the walls 
of the abscess ; even in them, however, the same operation 
must not be repeated after pus has again been formed, but a 
more extensive and radical operation is to be undertaken. 
Aspiration is always contraindicated in the empyema of 
adults, except in a vital indication for temporary relief, or 



DISEASES OF THE RESPIRATORY ORGANS. 351 

when the fluid is hemorrhagic in character, or in cases abso- 
lutely inoperable. 

During the operation the patient, if it be feasible, ought to 
be kept as much as possible on the diseased side, so as to avoid 
the dyspnoea due to the compression of the lung of the oppo- 
site side and the molestation of the heart. The serum may 
be permitted to flow so long as the current remains equable 
during inspiration and expiration; the discharge must be 
stopped when the current begins to cease during inspiration. 
The relief given by the removal of a half-pint or a pint is 
sometimes considerable; but in young children, with their 
compressible chests and corresponding facility of accommoda- 
tion to the expanding lung, it is safe and advisable to entirely 
empty the cavity. If the operation — because of the urgency 
of indications — be performed while exudation is still pro- 
gressing, and dyspnoea return, another thoracocentesis may 
become necessary within a short time. I have had to operate 
twice within a day. 

The operation requires time. It is advisable to interrupt the 
discharge from time to time ; for the too rapid entrance of 
air into the bronchi causes violent attacks of coughing (er- 
roneously attributed to the needle irritating the pulmonary 
pleura), or the sudden rush into the expanding lung may give 
rise to large quantities of serous, strongly albuminous, bron- 
chial secretion, or to copious pulmonary oedema, or to hemor- 
rhages with slight surface lesions, or even to considerable rupt- 
ure of pulmonary tissue. Fainting spells are also frequent 
during a rapid escape of serum, sometimes through psychical 
influences, sometimes from cerebral anaemia. In other cases 
(fortunately, rare) thrombi formed in the compressed lung, or 
in the impeded heart, or in the torn surface of the bronchi 
may be carried off into distant blood-vessels ; thus, emboli 
are known to have been swept into the pulmonary artery or 
into the artery of a fossa Sylvii. 



352 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

After the operation the wound must be cared for as I sug- 
gested above, when speaking of the treatment of a mere punct- 
ure made for the purpose of a diagnosis. In addition, it is 
advisable to enforce absolute rest and to apply for some time 
an ice bladder to the part. This is particularly necessary 
when there is acute pain. Should this be severe, morphia 
may be used subsequently, but in uncommonly small doses, 
because its absorption is very rapid and its effect much more 
marked here than under ordinary circumstances. 

The simple operation of aspiration does not suffice in cases 
of exudative pleurisy in which the pleural contents hold, or 
consist of, pus, either laudable or putrid. As I mentioned 
before, pus may be found as early as the fourth day, and then 
it is often on both sides. When high fever attends such cases, 
far from contraindicating a radical operation, they require it 
for immediate relief. If such relief be not obtained after 
a reasonable time, it is either because of a complication such 
as pneumonia, pericarditis, or peritonitis, or of some pus con- 
cealed in a recess. The latter ought to be looked for aud 
made to discharge ; Nelson employed a metal sound for the 
purpose of breaking up adhesions and facilitating the escape 
of pus. 

The radical operation consists in the making of a large 
aperture, either by simple incision between two ribs, if pos- 
sible, in the fifth or sixth intercostal space between the mam- 
millary and axillary lines, or by incision with the exsection 
of a piece of rib from one-third of an inch to an inch in 
length, large enough to admit two fair-sized drainage-tubes. 
The opening is insufficient so long as it gives no exit to the 
clots of fibrin, which sometimes are as large aud perplexing 
as their presence is unsuspected. It is on their ready and 
speedy removal that the duration of convalescence or the 
favorable or fatal termination depends. Thus, there are those 
who, as the presence or absence of these large masses can- 



DISEASES OF THE RESPIRATORY ORGANS. 353 

not be diagnosticated, insist upon exsection in every case of 
empyema, no matter whether of recent date or of long stand- 
ing. At all events, whenever there has been a continued or a 
pysemic fever, a great deal of pain, an intercostal oedema, or 
a complication with infectious embolism, pyopneumothorax, 
tuberculosis, or superficial pulmonary or hepatic abscess, the 
exsection of a large piece of rib is indispensable. When 
fistulse remain behind, or the abscess cannot close because 
of the lung being kept from expanding by pleuritic thicken- 
ing over it, larger pieces of one or more ribs must be removed 
to enable the chest wall to sink in and thereby facilitate the 
approximation of the walls of the cavity. In these, as in 
many simpler cases, it is necessary to keep the opening patent 
for a long time; this is readily accomplished through the 
slowness of the growth of callus in that region. 

After the operation has been completed, the cavity must be 
thoroughly washed with quarts of warm solution of corrosive 
sublimate or of Thiersch's mixture (boracic and salicylic acid) 
until the irrigated fluids return clear, and a thick aseptic 
dressing should then be applied. The frequency of the re- 
moval of this dressing and the number of injections depend 
on the nature and quantity of the pleural secretion. In the 
majority of cases it is safe to wait until the dressing becomes 
moist. When the lungs expand readily, many days may 
elapse before the first dressing is removed and another one 
substituted. When, however, the pus is putrid, and in cases 
of complications such as are mentioned above, a daily change 
of dressing and daily irrigations, with occasional short inter- 
ruptions, must be resorted to. 

Hydrothorax (fluid with a low specific gravity, less than 
1015, and from one to five per cent, of albumen) depends on 
or is complicated with malaria, nephritis, cardiac disease, 
anaemia, or cachexia. The cases resulting from scarlatina are 
among the most favorable. Besides the indications afforded 

23 



354 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

by its cause, and good nutrition, hydrothorax demands diuret- 
ics, such as digitalis, sparteine sulphate, caffeine, diuretin, bitar- 
trate of potassium. The less such patients drink the more 
readily will the fluid be absorbed. Plenty of sodium chloride 
in food and drink will increase renal action. If no reduction 
of the fluid take place, paracentesis is demanded. 

Pneumothorax is a complication or a result of the perfora- 
tion of a cavity, of pulmonary gangrene, of pleural infarctus, 
or of perforating empyema, and in many cases of this kind 
pyopneumothorax will be observed. Foreign bodies are more 
apt to produce pneumothorax than hooping-cough, which is 
liable to tear the mediastinum rather than the pleura. Ice 
will relieve local inflammation and pain, so will opium, 
which, moreover, modifies the perturbed respiratory move- 
ments. Cases of pyopneumothorax which do not readily dis- 
charge their pus through the lungs demand a counter-opening 
of the chest wall. 



DISEASES OF THE ORGANS OF CIRCULATION. 355 



IX. 

DISEASES OF THE ORGANS OF CIRCULATION. 

Both in acute and in chronic diseases of the heart the amount 
as well as the quality of food require some modification. In 
many cases the loss or diminution of appetite will regulate 
the former. As a rule, however, the amount taken ought to 
be much less than the same person would take when in health. 
Not only ought the total quantity to be less, but also that 
consumed at each meal should be comparatively small. It is 
best, therefore, to divide the meals into halves and even thirds, 
so as to cause the patient to eat every two or three hours. 
Digestibility must be improved by slow eating. The dia- 
phragm should not be annoyed by large quantities of food or 
by the evolution of gases. Therefore but few carbohydrates 
and but little fat are to be given, and the digestion of nitro- 
genous foods, such as meats (eggs) and milk, with or without 
cereals, ought to be aided by pepsin and dilute hydrochloric 
acid. The latter is an excellent adjuvant to the digestion of 
milk prepared according to J. Rudisch's formula (p. 23). Or 
it may be modified or mixed according to the rules given by 
me in my treatise on the intestinal diseases of infancy and 
childhood. At all events, milk is the main food to be given in 
cardiac ailments. Its digestion will have a further advantage 
in this, that it does not result in the physiological congestion 
of the stomach, liver, and spleen, which becomes irksome after 
large and heavy meals by disturbing the circulation and 
thereby adding to the labor of the heart, and that it does not 
contain the large mass of fat-forming elements present in 
the mixed food of healthy advanced childhood or adult age. 
In milk the proportion is: fat, 1 ; albuminoids, 1.44 ; sugar, 
1.63 ; in mixed food, however, 1 ; 1. 58 ; 6.04 carbon hy- 



356 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

drates. Altogether, it is best to slightly underfeed the patient. 
Thereby the labor of the heart is facilitated, an object which 
must never be lost sight of. For the same reason fast drink- 
ing, even of water, must be avoided, for its sudden absorption 
fills the blood-vessels too suddenly for comfort. Its speedy 
elimination does not diminish the momentary overwork. This 
warning is of particular importance as regards iced liquids, 
which act both by their bulk and by reflex. This advice is 
by no means superfluous, either for medical men or for the 
sick. It was strongly urged by Williams fifty years ago. 
Stokes prohibited the use of large quantities of soups or milk. 
And it has been again introduced by Oertel with such im- 
pressive emphasis that thirsting has become almost fashionable 
and a craze among the fanatics. 

That stimulants, such as coffee, tea, and alcoholic beverages, 
must not form part of the regular diet in cardiac disease is 
self-understood. They may be required as medicinal agents, 
however, upon positive indications. 

In every form of cardiac disease absolute rest of both body 
and mind is among the very first indications. The latter is 
just as important — perhaps more so — here as in diseases of the 
nerves and nerve centres. Fretting, worrying, crying, are 
detrimental, and must be avoided. Tims, it may become neces- 
sary to take a child out of bed, temporarily, to gratify and 
quiet it ; or to change its position, for the recumbent position 
of an hypertrophied heart may cause dragging of the phrenic 
nerve or of the sympathetic plexus ; or to raise the trunk and 
head to relieve the intra-cranial hyperemia and the consecu- 
tive irritation of the pneumogastric nerve ; or to give a mild 
opiate or a dose of bromide of potassium to insure quietude or 
sleep. The child must be permitted to select his own position ; 
he knows best where he is most comfortable ; but rest he must. 
The diseased heart is in its most favorable condition when 
working least ; the number of heart-beats is reduced by ten or 



DISEASES OF THE ORGANS OF CIRCULATION. 357 

twenty-five in the recumbent position. .Rest is not only a 
curative, but a preventive agent. Many a life-long cardiac 
affection could be warded off if care were taken in time. We 
are beginning to become more and more aware of the fre- 
quency of affections of the heart muscle. Myocarditis in a 
chronic, subacute, and acute form is of very frequent occur- 
rence. In or after every case of typhoid fever, scarlatina, 
diphtheria, or small-pox we must be prepared to be overtaken 
by some cardiac disease, either interstitial myocarditis or paren- 
chymatous degeneration. Kest in bed or on the lounge (the 
former is better) will act as a preventive. It ought to be 
continued for weeks in almost every case. Like the paralysis 
consequent upon infectious diseases, which develops after 
weeks, heart-disease may occur from the same cause, partly as 
a consequence of actual primary alterations, partly of nerve 
exhaustion. So long as the pulse becomes more rapid on 
exertion, or on getting out of bed, absolute rest is the best 
remedy and safeguard. In these cases it is not always possi- 
ble to distinguish between functional debility and actual disease. 
Autopsies too frequently tell us of our mistakes. Trifling 
changes in size cannot be measured by percussion, feeble mur- 
murs cannot always be estimated according to their exact 
value. Functional murmurs are not so frequent in the child 
as in the adolescent or the adult. On the other hand, organic 
cardiac diseases have a better chance to be cured — really cured 
— in the young than later. So much the greater is the re- 
sponsibility of the medical man in cases of preventable or 
remediable cardiac disorder. Even patients suffering from 
the very worst forms are apt to feel better within a very few 
(hours or) days after being confined to bed, with strict diet 
and loose and comfortable clothing. These cases teach us 
the lesson of what can be accomplished through the same 
regime in milder or incipient forms, by reducing the labor of 
the heart and at the same time of the voluntary muscles, 



358 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

and by diminishing the overactivity as well of the general 
innervation as of the cardiac nerves, both exciting and in- 
hibiting. 

It is difficult to decide to what extent exercise should take 
the place of rest in individual chronic cases. The hearts of 
patients are as little alike as are their noses and finger-tips, 
and their treatment ought to be as individual as the size and 
shape of their gloves. Neither fit everybody. Nor is the 
rule adopted to-day that which will accomplish the best end 
in a month or a year for the same patient. The heart is 
neither in health nor in disease a uniform body. Its innerva- 
tion may change from minute to minute, its nutrition is de- 
pendent on sudden or gradual alterations. A heart muscle is 
influenced in its arterial supply, venous discharge, and lymph 
circulation not only by its own health or disease, but by the 
ever-changing conditions of the other organs. Thus, many 
of the rules given one day may not remain valid another. 
Still, after a fair time has elapsed since the occurrence of an 
acute myocarditis or endocarditis, exercise should be recom- 
mended. The child may get up and have his quiet play sit- 
ting at the table, may begin to walk on the level floor, and 
may indulge in mild gymnastic exercise. More must not be 
permitted until the mucous membranes become a little more 
tinged, the arteries fuller, the heart quite regular. The sys- 
tematic rules recommended by Stokes and by Oertel refer 
more to adults, with their incipient fatty degeneration and 
chronic myocarditis, than to children. In these, while they 
bear the imprint of cardiac changes, no iron-clad rules hold 
good. Gentle exercise and long rest should alternate. 

The skin requires judicious attention. Exposure to cold, 
with its consecutive contraction of the cutaneous blood-vessels, 
overloads the viscera, retards circulation, and increases the 
labor of the heart muscle. A cold general bath, therefore, is 
dangerous (as also in the atheromatous degeneration of the old) 



DISEASES OF THE ORGANS OF CIRCULATION. 359 

in acute carditis (where local application of cold acts quite 
favorably) or in extreme muscular weakness of the heart. 
On the other hand, a brief cold sponge-bath or wash, with 
thorough friction, is an intense stimulant and may be used to 
advantage for a weak heart, unless the extremities be cold and 
the mucous membranes cyanotic. In these latter conditions, 
hot washes and frictions, with or without alcohol, should take 
its place. In the average condition of the diseased heart gen- 
eral hot bathing must be avoided. It overstimulates and para- 
lyzes, and proves an actual danger in both acute and chronic 
cases. Newspaper readers will remember the reports of people 
who go to the hot or " Turkish" bath with their heads erect 
and full of their own therapeutical wisdom, and leave it with 
their feet forward. A warm bath, the temperature of which 
ought not to be over 90° or 92° F., is often relished. Both 
the talking child and the silent, in fact, will soon tell you the 
exact temperature best adapted to their wants. In these cases 
requirement and comfort are identical. The baths, particu- 
larly the first, must be limited to a few minutes ; at all events, 
they should never be continued after the slightest change in 
the pulse is noted. The debilitating or fatiguing effect of 
the bath must be avoided. 

The mineral springs which have obtained a reputation 
in the treatment of chronic heart-disease, like the German 
Nauheim and Oeynhausen, owe their effect to the stimu- 
lating action of the salts and carbonic acid contained in 
them. 

Like hot water, hot air is contraindicated in heart-disease. 
The wilted forms of the little ones soon show the effects of 
summer heat. A temperature of from 65° to 70° F. and fairly 
dry air are best for them. High altitudes do not agree with 
cardiac disease, particularly w T hen no compensation has facili- 
tated the heart's action. Compensation is not complete until 
the hypertrophied left ventricle, having become so by mitral 



360 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

incompetency, transmits as much blood into the aorta as the 
pulmonary artery does into the lungs. Until that stage has 
been reached, the lungs are comparatively hypersemic and 
subject to catarrh, oedema, or bleeding. In this condition, 
therefore, the influence of the rarefied air of the high altitudes 
must be avoided ; as a rule, I recommend an altitude of not 
more than one thousand to fifteen hundred feet to childreu 
affected with chronic endocarditis. 

The drugs and remedies of the Pharmacopoeia applicable 
to the treatment of the several diseases of the vascular sys- 
tem being the same, a few general remarks on those I mostly 
employ will save repetition. At the head of the list is dig- 
italis. It increases the action of the heart muscle and 
thereby increases cardiac pressure. It is indicated in all 
conditions of weakness of the heart muscle so long as the 
latter is not decomposed. This condition hardly ever occurs 
primarily in childhood, for uncomplicated fatty degenera- 
tion in which digitalis is contraindicated is almost unknown 
at an early age. Secondary parenchymatous degeneration is 
a frequent occurrence in and after infectious diseases such as 
typhoid fever, dysentery, rheumatism, scarlatina, diphtheria, 
and others. Digitalis is useless and sometimes worse than 
useless in nervous affections such as the palpitations of Graves's 
disease, of neurasthenia, or of fever. In all probability the 
effect of digitalis is mostly felt at first in the left ventricle, 
which is more muscular, but in the right ventricle almost as 
soon. By acting on the left ventricle it regulates the gen- 
eral circulation and facilitates aspiration of the venous blood 
and the circulation in the lungs and in the right heart. 
During its administration the contractions of the heart be- 
come more vigorous and less frequent, the arterial pulse slower 
and fuller, the urine increases in quantity, cyanosis and dysp- 
noea diminish, and dropsical symptoms gradually disappear. 
When large doses have been given for some time, cumula- 



DISEASES OF THE ORGANS OF CIRCULATION. 361 

tion of the effect takes place. The pulse becomes quite slow 
and irregular, and vomiting sets in. If possible, this effect 
must be avoided. 

For how long a time may digitalis be administered when 
given in moderate doses ? This question has often been asked 
and as often answered. Unfortunately, the preparations sold 
in the markets are of different strengths and vary too often ; so 
it is best to rely on preparations which are not liable to spoil 
on one's hands. With that proviso, I can say, from an experi- 
ence of several dozens of years, that I cannot agree with those 
who stop the administration of digitalis after a few days, to 
begin again after an intermission. Moderate doses may be 
given day after day for months without any ill effect and with 
great benefit. Nor is it necessary to alternate between cardiac 
stimulants so long as no uncomfortable digitalis effect makes 
its appearance. 

In practice we are often disappointed. The preparations are 
as various as are the firms of wholesale, or sometimes retail, 
manufacturers or tradesmen. The United States Pharma- 
copoeia is, after all, the best stand by of the practitioner, and 
its list of drugs and that of the National Formulary of the 
Pharmaceutical Association are sufficiently large to supply any 
taste. The infusion of digitalis, when reliable, may be given 
to a six-year-old child in doses of a teaspoonful two or four 
or five times a day, the fluid extract (I have often expressed 
my predilection for " Squibb's") two or three minims daily, 
the solid extract from one-half to one grain daily. Indeed, 
children bear digitalis, and cardiac stimulants generally, better 
than adults, and in comparatively larger doses. Digitalin I 
have used a great deal. Unfortunately, the wares sold by 
that name are very unequal : they are resinoids, not alka- 
loids. In order to have — no matter whether resinoid or alka- 
loid — an article of probable uniformity, I prefer to prescribe 
Merck's. A child of six years may take one-hundredth of a 



362 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

grain from three to ten times a day. I have often been 
obliged to give much larger doses to obtain an effect ; for, 
while in chronic cases we may safely spend some time on de- 
veloping an effect, in urgent and acute cases one or more large 
doses should — nay, must — be given to accomplish the desired 
end immediately. In urgent cases a six-year-old child must 
take from one to five minims of the fluid extract at once. That 
dose may be repeated after a few hours, and perhaps again, 
until the effect is perceptible. Then it is time to slacken off 
or stop altogether. It is particularly in those cases in which 
the pulmonary circulation is obstructed, either by local inflam- 
matory processes or by cardiac incompetency, that this mode 
of proceeding is advisable. 

The effect of digitalis is not limited to the heart ; the 
arteries are also affected by it. On this account digitalis is 
often contraindicated in senile affections of the whole vas- 
cular system. As they (atheromatous conditions) are not 
found (except in a few stray cases of literature) in infancy 
and childhood, this contraindication is rare in early age. 
There is a single exception, however, to this rule — viz., in 
abnormal congenital smallncss of the arteries, which is not 
so excessively rare as may be presumed, and is a frequent 
cause of life-long migraine, neurasthenia, hysteria, and chlo- 
rosis. In these conditions, thus caused, digitalis is not well 
tolerated. 

In those cases in which the effect of digitalis appears to be 
retarded, or the practitioner has " reason to doubt the quali- 
ties of his drug," another one may be substituted for it or 
combined with it. The tincture of strophanthus may be 
taken by the same child to the daily amount of from six to 
twenty-five minims ; the fluid extract of convallaria majalis 
in the same or somewhat larger doses. Again I suggest that 
in most cases it is best to ascertain the moderate dose to be 
administered a long time in succession by giving a good dose 



DISEASES OF THE ORGANS OF CIRCULATION. 363 

from the very beginning and watching its effect. Of the sul- 
phate of sparteine (better than other preparations of scoparius) 
eight or ten doses are required daily, altogether amounting to 
from one-half to one and a half grains. Caffeine from two 
to ten grains, or the salicylate (or benzoate) of sodio-caffeine 
from four to fifteen grains a day, are fair doses, the effect of 
which will be pleasant in most cases. In a former chapter 
of this book (p. 81) I have alluded to the subcutaneous use of 
the latter, as it dissolves readily in twice its weight of water 
and is not a local irritant; therefore it is easily employed. 
The effect of these injections is often marked. More than a 
dozen years ago I published a case of cardiac pulmonary 
cedema, among others, in which recovery was the undoubted 
result of their use. There is, however, a positive contra- 
indication to the use of caffeine (and coffee), — viz., cerebral 
hyperemia, either active or passive. The salicylate of sodio- 
theobromine has been introduced (as "diuretin ,? ) by G. See. 
It is a diuretic rather than a cardiac stimulant, and, like the 
former, it is often found wanting. Calomel in small doses is 
certainly a cardiac sedative, and as it is surely a diuretic, it 
is entitled to the many praises bestowed on it rather by the 
older than by modern physicians. Salines owe their effect 
upon the heart mainly to their action on the digestive and the 
urinary organs, with the exception of the bromides and 
iodides, the former of which act as sedatives and thus save 
labor and soothe irritation. The iodide of potassium has a 
more direct effect. It dilates arteries, diminishes arterial ten- 
sion, and aids elimination through the bronchial mucous mem- 
branes and the kidneys. Obstructions of the pulmonary cir- 
culation depending on the heart are its happy indication. 
Sclerosis of the coronary arteries is not found in the young ; 
therefore this is an indication exclusively belonging to ad- 
vanced age. A child of six years may readily take from five 
to twenty grains a day, in three or four doses, in plenty of 



364 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

water, after meals. It need not often be interrupted because 
of the gastric symptoms produced. 

There are occasional cases in which the secondary com- 
pensation required by mitral incompetency is not fully es- 
tablished, and serious disturbances of the circulation arise 
therefrom. The dangerous symptoms may be cyanosis and 
pulmonary (or) and cerebral oedema. There are stupor or 
convulsions, dyspnoea, cyanosis, dilated veins, cold extremi- 
ties, and a small and intermitting pulse. It is in these cases 
that a few of the above-mentioned large doses of digitalis 
may do good ; here it is that wavering and indecision become 
criminal. Whenever digitalis does not have any effect, a 
venesection may. Our ancestors were less pusillanimous. 
Maybe they overdid bleeding, but in an urgent case they did 
not fail to do it. I know that I have several times saved 
the lives of children (and adults) by opening a vein quickly. 
Once it was the jugular. 

Chronic (and sometimes the final termination of acute) car- 
diac diseases may lead to heart-failure. In such cases stimu- 
lants are indicated. Alcohol must not be given by itself 
and in large doses in cerebral hypersemia of any kind. A 
child of six years may take from three to twenty grains of 
camphor internally ; subcutaneously, a solution of one part in 
five of sweet almond oil should be used, and from five to fifteen 
drops injected repeatedly. Ether may be given, in doses of 
from three to ten drops, in alcohol and water, and ammonium 
carbonate, in frequently repeated doses of from one-half to 
two grains, in anise-seed water or in milk. Siberian musk 
internally, strychnia subcutaneously, are required. The more 
urgent the case appears to be the greater is the indication for 
combining several of these remedies. 

Myocarditis. — Though myocarditis, both acute and chronic, 
is by no means so frequent in the child as in the adult, it is 
nevertheless not infrequent ; it is, indeed, remarkable to ob- 



DISEASES OF THE ORGANS OF CIRCULATION. 365 

serve how often it is not diagnosticated, or how little its occur- 
rence is appreciated. The disease is met with either in con- 
nection with endocarditis, pericarditis, rheumatism, etc., or is 
spontaneous and uncomplicated. 

In its treatment muscle stimulants must not be given. Dig- 
italis is contraindicated. The recommendation of Heffen, to 
administer ergot, I cannot approve of, for by its action on the 
muscular fibres it increases vascular pressure, and thereby 
secondarily the labor of the inflamed heart muscle. What- 
ever relieves this temporarily is welcome. Therefore, iodide 
of potassium combined with a bromide will act favorably. 
This is also the place for morphia, either in large doses at 
long intervals or in small doses more frequently repeated, to- 
gether with ice to the chest. During attacks of collapse, or 
during weakness or prostration, ether, camphor, and alcohol 
should be given, either internally or in an urgent case subcu- 
taneously. A dose of calomel to relieve the bowels. Ene- 
mata for the same purpose daily, for regular evacuations are 
the best regulators of intra-abdominal circulation. In chronic 
cases iron may safely be given with the iodide ; not in acute 
ones, which are injured by it through the increase of vascular 
irritation. Absolute rest, both physical and mental, is essen- 
tial. The extremities must be kept warm. 

Endocarditis. — The treatment of this disease is more promis- 
ing in the child than in the adult, for entire recovery is more 
frequent in early life than later ; but it is important that the 
diagnosis should be made early. In order not to be taken un- 
awares, we ought to remember that endocarditis may be present 
without exhibiting a murmur, at least for some time ; there are, 
indeed, cases which run their full course without a murmur. 
This is eminently so in ulcerous endocarditis. On the other 
hand, it is also necessary to remember that functional murmurs 
are not so common in the child as they are in the adult. Thus, 
every murmur — though there be no hypertrophy developed as 



366 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

yet — must be suspected of being dependent on organic disease. 
Tiiis may also be suspected in most cases of acute chorea, 
which sometimes precedes and ushers in, instead of following, 
endocarditis ; and in every case of articular rheumatism, the 
symptoms of which have been described by me in a former 
chapter of this book as sometimes so slight as to be easily 
overlooked (p. 205). Acute endocarditis is also common as 
a sequela of the chronic form, and as part of septico-pysemia. 
It is not uncomraonas the result of acute and chronic nephri- 
tis, and of infectious diseases, such as scarlatina, measles, 
typhoid fever, variola, tuberculosis, and carcinosis, and is fre- 
quently complicated — mostly through the intercession of peri- 
carditis — with pneumonia and pleurisy. Frequent and careful 
examination, therefore, during the existence of such ailments, 
while it facilitates an exact and complete diagnosis, suggests 
the best method of prophylaxis. Most of the cases of endo- 
carditis we meet with in children being due to acute rheuma- 
tism, every case of the latter, though ever so slight, must be 
watched, put to bed, and treated with salicylate of sodium. 
Almost every form of " growing pain" ought to be so treated, 
and in no case of infectious disease must the patient be per- 
mitted to leave the bed before much of the previous strength 
has been restored. 

The special treatment of acute endocarditis requires abso- 
lute rest in bed, a dose of calomel sufficient to open the bowels, 
and regular discharges through the course of the disease rather 
by means of enemata than of purgatives. Frequent but small 
meals, and articles of food as suggested before. If thirst be 
great, drinking should be permitted often rather than much 
at a time. No alcohol in the beginning. Depletion by 
leeches is rarely indicated, and then only when there is a 
serious complication with painful pleurisy. In rheumatic 
endocarditis depletion is not tolerated at all. For severe pain 
which depends on pleural complication the subcutaneous injec- 



DISEASES OF THE ORGANS OF CIRCULATION. 367 

tion of a few drops of Magendie's solution of morphia is 
preferable. Dry and wet cupping will sometimes relieve in 
such cases ; other derivants, such as sinapisms, will often suf- 
fice. Vesicatories I do not advise in an acute case, the patient 
having enough to suffer from nature's infliction. Ice applied 
in a bag, which must not be too heavy, or ice-water cloths 
well wrung out, are beneficial in most cases, rheumatic or other. 
The head and trunk must be raised so as to make the patient 
as comfortable as possible. Blue ointment has been recom- 
mended over the heart and other places. I cannot say that I 
have reason to advise it. Strong diuretics, such as act by 
increasing blood-pressure, must not be given ; mild salines 
will answer best ; a small dose of calomel may be given from 
time to time. According to the indications noted above, iodide 
of potassium, with or without an opiate, will answer best, in 
doses of from fifteen to twenty-five grains daily, for a child of 
six years. An opiate at night secures rest ; bromide of potas- 
sium may be given through the day. If the case be rheumatic, 
as it mostly is, salicylate of sodium, from fifteen to thirty grains 
daily, will be tolerated and found serviceable. Phenacetin may 
take its place sometimes, in daily doses, all told, of from eight 
to twenty grains. It acts as a febrifuge, an antirheumatic, 
and a sedative at the same time, better than quinine, a dose of 
which may, however, answer well now and then, particularly 
during remission. No antipyrin, no acetanilid (" antifebrin" of 
the trade). Serious attacks of dyspnoea are best relieved by 
morphia, either internally or subcutaueously, or by lead and 
opium. Drastics will seldom be required and seldom answer 
the purpose. The nitrites may be tried, though they have not 
served me so well, or so often, as I formerly thought I had 
reason to expect ; they act best when the pulse is dangerously 
small. When cachexia and debility are prominent symptoms, 
tonics and stimulants are indicated early. In septic cases the 
chloride of iron should be given at an earlier period than 



368 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

in those of a purely inflammatory or rheumatic character. 
Among the stimulants, I think highly of camphor and am- 
monium. Among the direct cardiac stimulants enumerated 
above, digitalis ought to be given only after the acute chauges in 
the muscular tissue of the heart have been repaired. (There 
is hardly a case of endocarditis unaccompanied by myocarditis.) 

It is here that the experience and tact of the practitioner 
have to decide an important point. In the further evolution 
of the case, digitalis with quinine, digitalis with belladonna, 
digitalis with strychnia, or with a bromide, or with an iodide, 
together with stimulation of the peripherous circulation by 
friction, either dry or with alcohol or hot or cold water, find 
their own indications. 

The hygienic treatment of chronic endocarditis has been 
disposed of in former remarks. The medicinal agents of most 
importance are digitalis and iron. Constipation and over- 
exertion must be avoided. In connection with the latter, the 
education and training of the child should be so guided as to 
prepare him for his future trade, business, or vocation. Endo- 
carditis terminating so often in valvular disorders with con- 
secutive hypertrophy, his future life ought not to be exposed, 
if avoidable, to great excitements or hard physical labor. A 
child so affected must not take coffee, tea, or alcohol in any 
shape as an article of diet. He must not be trained to be- 
come a military man, a pugilist, a mason, or a medical practi- 
tioner, unless he make up what he would call his mind to 
turn to a fashionable specialty at the age of twenty-one, com- 
pile a text-book, and earn greatness and millions with ease 
and comfort while sitting in his office. 

The management of valvular changes resulting from endo- 
carditis is more successful in childhood than in the adult. 
Compensation is brought about by consecutive hypertrophy ; 
thus it is facilitated, about puberty, by the rapid increase of 
the heart at that period of life, and particularly by the in- 



DISEASES OF THE ORGANS OF CIRCULATION. 369 

crease in size of the aorta and also of the arteries in gen- 
eral, thereby easing the circulation. Besides, vascular disease, 
which is so common in the adult, is a rare exception in the 
child. Moderate exercise contributes its share in increasing 
the growth of muscular tissue of all kinds, and should be 
recommended, according to Beneke.* 

Pericarditis. — The pericardium is more accessible to the in- 
fluence of cold applications in this than in any other form of 
acute heart-disease. They generally act well ; but we must be 
prepared to meet with doubtful or no success in many cases, 
for pericarditis is but rarely a primary disease. Myocardial 
changes (fatty degeneration mostly in the adult), chronic in- 
terstitial myocarditis, or tubercle, or syphilitic gumma, or 
complications with purulent mediastinitis or pleuritis, are 
not uncommon. In pneumonia, pleurisy, rheumatism, and 
scarlatina pericarditis is not unusual. The internal treat- 
ment of pericarditis is, therefore, in part guided by the 
complications. Digitalis is indicated mainly in cases which 
are rather complicated ; strophantus, convallaria, and iodide 
of potassium may take its place or be combined with it. 
Morphia is demanded in most cases, if only to give rest for 
the night. The fever may require phenacetin or (during a 
remission) quinia. After the fever has disappeared, or while 



* From birth to the seventh year the volume of the heart increases from 
twenty-three to one hundred cubic centimetres, by no means in proportion 
to the weight of the body. Still, this increase is very much greater than 
that of the lumen of the arteries when compared with the length of the 
body. The pulmonary artery is wider than the aorta until puberty ; after- 
wards they are equal or the aorta becomes larger. The subclavian arteries 
and the common carotids are very wide compared with the length of the 
body (thereby causing physiological and pathological congestions of the 
cranium and its contents). Between seven and fifteen years the volume 
of the heart is from one hundred and thirty to one hundred and forty 
cubic centimetres ; at that time the large arteries increase in absolute 
width, in accordance with the rules given before. 

24 



370 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

it is waning, absorption of the effusion may be promoted by 
caffeine, sparteine, diuretin, iodides, and a vesicatory over the 
heart. Effusion into the pericardium is not often so copious 
as to produce suffocation, but I am afraid that puncture of 
the pericardium to relieve the fatal pressure is not made so 
often as it ought to be. Fortunately, errors in the diagnosis 
are not very easily made ; still, they do occur, for I have been 
called to perform paracentesis where there was some pericar- 
ditis, more hypertrophy, and much pleurisy. The operation 
is not difficult, the liquid being so copious as to give the heart 
ample space to recede in a semi-recumbent position. The 
aspiration can be made in the mammillary line, in the sixth 
intercostal space. In the same neighborhood, at the upper 
margin of the fifth or sixth rib, the incision can be made to 
remove pus, and injections made afterwards. Drainage has 
also been established in such cases. The heart has been 
punctured during the aspiration without evil result j but I am 
not prepared to say, even with Biedert, that " the puncturing 
of the heart is not connected with any danger." 

Hydropericardium, no matter from what cause originating, 
must be treated on the same principles as those which are 
valid for hydrothorax. 

Syphilis of the pericardium and of the heart, if diagnosti- 
cated, require their own specific treatment. 

Congenital anomalies of the heart are apt to claim attention 
from the moment of birth. The newly-born candidate for 
cyanosis is liable to suffer from asphyxia, the rules for the 
treatment of which need no repetition here. As the troubles 
are incurable, being the result of embryonic arrests of de- 
velopment or of foetal inflammations, almost the only thing to 
be done for the little sufferers is to protect them as much as pos- 
sible. If they be so unfortunate as to grow up, exercise should 
be avoided, — indeed, is avoided. Alcohol is indicated in con- 
ditions of collapse only ; no blood must ever be taken ; laxa- 



DISEASES OF THE ORGANS OF CIRCULATION. 371 

tives should be but sparely given. The temperature in which 
the little waifs are to live ought to be equable, moderately 
warm, their wearing apparel warm and comfortable. Conges- 
tive disorders which would require the use of cold in other- 
wise healthy children must mostly do without it, as they 
seldom bear it. Mild vegetable acids are coveted by most. 
Only those who appear to develop hypertrophy of the heart 
should take digitalis. Small doses of an opiate will often 
relieve their discomfort and dyspnoea. The combination of 
digitalis with iodides, administered for months in succession, 
gave relief in a number of cases where the patients lived four 
years and more. 

Congenital undersize of the heart does not appear to be so 
frequent as that of the arteries. Indeed, in many cases of 
undersized arteries it was found of normal size, or somewhat 
larger. In the latter case the heart was not always hyper- 
trophic; on the contrary, in most instances there was fatty 
degeneration. Like every small organ, the small heart, when- 
ever found, may be built up by moderate and persistent exer- 
cise. A certain amount of hypertrophy will probably result 
from it, but the labor of the heart must be done either by an 
organ of sufficient size or one of unusual strength. 

Blood-vessels. — The structure of the blood-vessels may be 
very defective, the walls being thin, fragile, and pervious. In 
such cases hemorrhage, small or copious, is a frequent symp- 
tom. The frequency of hemorrhages in the newly-born, lead- 
ing to asphyxia, convulsions, idiocy, or early death, is caused 
by the thinness of the vessel walls, whose tissue has not yet 
evolved from its embryonal condition. This, or a similar 
condition, may continue for life. This hypoplastic state, how- 
ever, is not, of necessity, general : it may be local. The early 
nose-bleedings of some, though they have no heart-disease, 
and the congenital tendency to aneurisms in places where the 
elastic tissue is either scanty or absent (mostly at the origin 



372 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

of branches), prove the occasional occurrence of these circum- 
scribed and local defects. A uniform thinness of the arte- 
ries, however, is most likely to be complicated by their 
narrowness, which has been studied by Virchow, See, and 
others in its relation to incurable chlorosis, palpitation, and 
cardiac asthma. That thinness which predisposes to fatty 
degeneration of the intima and media, to sclerosis of the ad- 
ventitia, to atheromatous endarteritis, and to the formation of 
aneurism at an early age has not been made the subject of 
active treatment, so far as I know, except by myself. The 
number of such cases is naturally small compared with the 
total number of a large practice or clinic ; but I feel convinced 
that the administration of phosphorus, — not phosphates of any 
kind, — with its stimulant effect on the growth of connective 
tissue in general, has rendered me good service in habitual 
tendency to cutaneous, mucous, and internal hemorrhages. 
Haemophilia of moderate degrees appeared to me to improve 
under its use, and the children to be safer and better de- 
veloped. The dose for a child of three years should be from 
one-fiftieth to one-thirtieth of a grain daily ; that means from 
two to three minims of the oleum phosphoratum, or from 
one to one and a half teaspoonfuls daily of the elixir phos- 
phori (United States Pharmacopoeia of 1890). 

Thrombosis of veins in general, and of the sinus of the dura 
mater in particular, is the result of retardation of the (gen- 
eral or) local circulation and of coagulation of blood by 
marasmus from whatever cause : rapid elimination of water 
(cholera infantum), debility of the heart, pressure on veins, 
or inflammation in the neighborhood (for instance, caries of 
the petrous bone). In the cranium the right transverse sinus 
is most frequently affected, but quite often also the inferior 
petrous, cavernous, and longitudinal sinuses. These throm- 
boses cause hypersemia, oedema, or extravasations ; these are 
the symptoms by which the diagnosis is made. The treat- 



DISEASES OF THE ORGANS OF CIRCULATION. 373 

ment must be preventive in order to be successful. Early 
attention to the ear and mastoid process, treatment of diar- 
rhoea before inspissation of the blood and heart-failure take 
place, timely stimulating and roborant treatment, and not 
pro re nata, — that is, when it is just a little too late, — are 
the best preventives. The subcutaneous injection of large 
quantities of warm sterilized water, with chloride of sodium 
(1000 : 7), is capable of preventing the inspissation of the 
blood which results from acute and copious diarrhoea, and 
often proves life-saving. 

Congenital local dilatations of blood-vessels, capillaries, 
smallest veins, and smallest arteries, together with an increase 
of their number, and mostly with incompetent structure, are 
known by the names nwous, telangiectasia, angioma. Their 
color depends on the nature of the blood-vessels composing 
the anomaly, also on their distance from the surface, their 
size on the extension of the morbid process, and their size and 
consistency on the admixture of connective tissue. They are 
found in all sorts of tissues and organs, mostly on the surface 
of the body ; in the subcutaneous tissue, when mixed with 
much connective tissue, they are liable, after having remained 
unchanged for many years, to undergo sarcomatous degenera- 
tion. Therefore, and because of their tendency to rapid 
growth in every direction, with increasing deformity and pos- 
sible danger from hemorrhage, the early removal of all those 
which do not exhibit from the beginning a tendency to fade and 
finally disappear is indicated. The methods followed to obtain 
that end are very numerous. Vaccination over a nsevus will 
generally destroy it, but may do so but partially, and will 
leave a bad scar. The plaster of tartar emetic and Vienna 
paste cannot be controlled to such an extent as to destroy the 
growth only. Injections of the perchloride or of the subsul- 
phate of iron are known to have given rise to extensive throm- 
bosis, gangrene, and death ; injections of alcohol have been 



374 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

tried, but have not, I think, reached further than the ear of the 
medical public. Corrosive sublimate in collodion (1 : 8) is an 
excellent caustic where the nsevns is not extensive, particularly 
on the head ; it rarely requires more than a single application. 
Fuming nitric acid is perhaps the best of all local applications ; 
the pain is but temporary, and the effect circumscribed and 
fairly thorough. But it ought to be used for superficial nsevi 
only, and even then must be repeated in a number of in- 
stances. Excision is a good method if the operation can be 
performed in a short time and all the morbid parts can be 
safely removed without loss of too much blood. The ligation 
of angiomatous tumors is indicated where they can be entirely 
grasped either without or with the aid of needles run through 
their base; but time is required for them to finally fall off, 
and the wound demands careful and persistent antiseptic treat- 
ment until the danger from local infection has passed and a 
smooth scar has been secured. Electrolysis has been praised 
very highly, particularly in the treatment of the extensive 
wine-marks. Still, personally, I never saw a satisfactory re- 
sult in these cases. There always remained speckled, whitish 
scars of small size alternating with the original discoloration, 
a result which I should not claim as an improvement upon 
the original condition. The actual cautery is the most satis- 
factory of all our remedies ; very few will at present use it 
in any other shape than that of the galvanic or the thermo- 
cautery. The heat must not be excessive ; white heat de- 
stroys blood-vessels too rapidly to permit of simultaneous 
coagulation of the blood, and produces hemorrhages. Dull- 
red heat will accomplish a cure. A momentary application 
suffices for a superficial nsevus; its action can always be 
controlled and strictly localized, and the formation of the 
scurf secures against surface infection. Nor are large angio-" 
mata inaccessible to it. When these are to be destroyed, it 
is best not to attempt too much at first. It is unnecessary to 









DISEASES OF THE ORGANS OF CIRCULATION. 375 

destroy everything ; long after the direct effect has passed 
away, coagulation in the blood-vessels and slowly progressing 
cicatrization result in the gradual lessening of the swelling. 
When the reduction of the nsevus ceases, the operation is 
repeated, sometimes after many weeks or even months. The 
cautery is then introduced into the very spot where the pre- 
vious application was made. In this way the surface cicatrix 
remains localized. As a general rule, a cicatrix following 
the application of the actual cautery is smooth and becomes 
more so and less perceptible from year to year. 






376 THERAPEUTICS OF INFANCY AND CHILDHOOD. 



X. 

DISEASES OF THE NERVOUS SYSTEM. 

The great indication in the treatment of all diseases of 
the nervous system attended by symptoms of irritation is ab- 
solute protection against external disturbances. Tin's is at- 
tained by equable climate, uniform temperature of the room, 
rest in bed, exclusion of light and noise, by comfortably warm 
clothing, warm bathing, warm applications and fomentations, 
and by the removal of any- and everything annoying and jar- 
ring. Therefore, children sick with nervous diseases must not 
be excited by unnecessary constraint or coercion, their medi- 
cines ought to be given in a palatable form, and vesicatories 
and other distressing applications avoided, if possible. Symp- 
tomatic treatment is perhaps more indicated than in the same 
class of ailments among adults. Pain and sleeplessness lead 
to speedy exhaustion. Nothing is more common and more 
dangerous than the prejudiced refusal to relieve pain by 
opiates and sleeplessness by properly selected narcotics. It 
is particularly in those cases which are mostly, or entirely, of 
a reflex nature that a symptomatic treatment ought to accom- 
pany that of the causal indications. It is ludicrous as well 
as criminal to withhold chloroform when an eclamptic attack 
results from an intestinal irritation, or an antispasmodic when 
a cough is caused by stomach, ear, or nose. 

In conditions of depression, debility, and paralysis the 
treatment should be stimulant, exciting, and roborant. In 
such cases the electric current is frequently employed, and is, 
to a certain extent, useful. Massage has a beneficial effect 
not only on the periphery, but by its general action on inner- 
vation and circulation, by its effect on the muscles, and also 
by its direct influence in increasing the relative circulation 



DISEASES OF THE NERVOUS SYSTEM. 377 

of the red blood-cells (John K. Mitchell). Strychnia stimu- 
lates (while curare depresses) the reflex and vaso-motor cen- 
tres. Nitrate of silver appears to exert a favorable influence 
in spinal paralyses ; rnuscarin, physostigmine, and nicotine in 
paralytic conditions of the uustriped muscular fibres. 

The interrupted electrical (faradic) current is an excitant — 
stimulant — of the nervous system, both locally and generally. 
For the latter effect general faradization has been practised, 
both through large electrodes and in the bath, to great advan- 
tage, according to many who have a right to claim a large 
experience. The generally stimulant effect does not, how- 
ever, disprove the fact that, like the galvanic, the faradic 
bath is capable, particularly when the fine wire coil is used, of 
reducing undue sensitiveness. The action of the galvanic cur- 
rent is claimed to show itself in different ways. It is stimu- 
lant and excitant, and (directly, or when interrupted by 
reversing), mainly when the brush is employed, produces pain, 
contraction, and consecutive dilatation of blood-vessels. It is 
electro-tonic, and thereby produces changes in the irritability of 
the tissues ; it is chemical, and thereby decomposes fluids ; and 
it is cataphoric, and thereby transfers solutions through badly 
conducting tissues. To the two poles different properties are 
attributed. It is the positive pole (anode) which is credited 
with a tranquillizing effect in inflammations and neuralgias 
(less in tic and hemicrania than in supra-orbital, occipital, inter- 
costal, lumbar, and sciatic neuralgias) ; the negative (cathode) is 
claimed to influence old inflammatory processes, cicatrices, and 
indurations. Still, there is no doubt in my mind as to the ex- 
aggerated character of the expectations once cherished in regard 
to the effects to be obtained by both electricity and galvanism. 
The difficulty of reaching a coveted spot through tissues of 
different conducting powers is always great ; the accumu- 
lation of fat is a powerful obstacle to the transmission of the 
current, and its amount cannot be calculated. This is so true 



378 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

that even for purposes of diagnosis the subcutaneous fat of 
babies aud many women offers a serious impediment. Besides, 
different morbid conditions and different periods of life inter- 
fere with the estimation of the effect of the current. In what 
has been called the reaction of degeneration both the faradic 
and the galvanic irritability of the nerves are diminished, and 
while the galvanic excitability of the muscles is preserved, the 
excitability by the faradic current is lowered. In the very 
young, — the baby under two months, — as general reflex irrita- 
bility is lowered, comparatively strong electrical influences 
are required to obtain effects. At all events, therefore, the 
action of the different currents is, to some extent, not meas- 
urable, controllable, or certain. The time during which both 
the faradic and the galvanic current were considered far- 
reaching and omnipotent remedies has long gone by. Indeed, 
there are those, particularly among neurological specialists, 
who, while maintaining that the currents are great aids for 
diagnostic purposes, yet reject their claims as curative agents. 
But lately Meltzer — in a paper read before the Association of 
American Physicians — has proved the total absence of efficacy 
on the part of the electrical current when applied to the mu- 
cous membrane of the stomach and the intestines. It is to be 
hoped that the exertions of the American Electro-Therapeutic 
Society will clear up many doubts and obtain results commen- 
surate with the enthusiasm which gave rise to its foundation. 

Franklinism, once the only recognized electrical remedy, 
has rapidly regained a standing, much of which is due to Dr. 
W. J. Morton, of New York. But neither the common 
disruptive discharges which he uses in locomotor ataxy nor his 
" static induced currents," obtained by adding condensers to 
the static machine, will find many applications among chil- 
dren affected with diseases of the nervous system. 

The effect of the electrical and the galvanic current is per- 
haps best exhibited in cases of peripherous nervous affections. 



DISEASES OF THE NERVOUS SYSTEM. 379 

Paralysis of the facial nerve and of the brachial plexus, both 
not infrequent after difficult or clumsy deliveries, are among 
those in which the current is frequently used ; its effect is 
mostly very slow, sometimes not very satisfactory. Particu- 
larly in cases of facial paralysis, where the reaction of de- 
generation has already been established, it leaves much to be 
desired. The same must be said of polyneuritis, — such as fol- 
lows infectious diseases, with its pain and increasing paralysis 
and degeneration, together with intact bladder and pupils, — 
in which rest, salicylate of sodium, and, later, strychnia yield 
better results than does the current. Nor is it more effective 
in hemicrania, no matter whether it be the result of congeni- 
tal disposition, or complicated with hysteria and epilepsy, or 
dependent on anaemia, hypermetropia, dyspepsia, overwork, or 
confined air. In all these conditions the correction of the 
causes, a convex glass, country air, shortening of school hours, 
cold-water treatment, arsenic, iron, and aconitia, with an occa- 
sional dose of a bromide, will yield better results. 

To complete what I have to say on the subject of the reme- 
dial influence of electricity and galvanism, I may as well speak 
here of their employment in the peculiar changes of the 
muscles which are known under the heads of muscular atrophy, 
progressive juvenile muscular dystrophy, and pseudo-hyper- 
trophy. All of these names are applied to abnormal conditions 
whose coarse anatomical changes are better understood than 
their causes. In a certain percentage (exactly as in Thomsen's 
congenital myotony) the alteration is in the beginning strictly 
local ; in others there can hardly be a doubt as to the cerebral 
origin of the muscular anomaly. In all of them electricity 
and galvanism have been extensively used, together with 
massage, bathing, etc., but in no case have their effects been 
noteworthy. As in many other cases where the original cause 
(or change ?) is inflammatory, and exhibits itself in proliferation 
of cellular interstitial tissue (no matter what its final result is 



380 THEEAPEUTICS OF INFANCY AND CHILDHOOD. 

destined to be), mercury, mostly the bichloride, — administered 
patiently and watched carefully, — appears to have given me bet- 
ter results. At least, the duration seemed to be longer and inter- 
missions of the morbid process more distinct and prolonged. 

Operations on the skull and brain are among the prides 
of modern operative surgery. Escapes from death on the 
table are more numerous than formerly, and recoveries from 
diseases formerly fatal, because permitted to die without an 
operation, are not infrequent. Craniotomy has been performed 
for injuries, intra- and extra-dural hemorrhages, hydrocepha- 
lus, softening, tumors and cysts, Jacksonian epilepsy, athe- 
tosis, chronic contractures, certain mental diseases, otherwise 
incurable headaches, old cicatrices, and abscesses. Infants and 
children come in for their share, mainly with abscesses, hemor- 
rhages, hydrocephalus, Jacksonian epilepsy, and premature 
ossification of the cranial bones and fontanels, with epilepsy 
and idiocy among its results. So far as craniotomy and cra- 
niectomy are concerned in cases of microcephalus or idiocy, 
no other surgeon has met with the favorable results alleged 
to have been obtained by Lannelongue. Guided by thirty- 
three cases of American surgeons, — fourteen of which died 
soon, while nineteen recovered, and very few showed any 
improvement, — I have treated of the subject in my address 
before the Eleventh International Medical Congress at Rome, 
April, 1894,* and have arrived at the following conclusions: 
that congenital idiocy is the result of many different forms of 
arrest of development (of blood-vessels, cortex, island of Reil, 
hemispheres), of inflammations (meninges, encephalon, with 
softening, or sclerosis), of thrombosis, and of hemorrhages; 
that it is a frequent result of microcephalus, which, as a rule, 
is not dependent on premature ossification of the bones aud 
fontanels, but in the large majority of cases on arrest of de- 

* "Non nocere," New York Medical Record, May 19, 1894. 



DISEASES OF THE NERVOUS SYSTEM. 381 

vclopmcnt of some parts of the brain, mostly connected with 
long-continued patency of the fontanels ; that, therefore, opera- 
tions undertaken to widen the cranial cavity are of no use, for 
a brain which did not grow before the cranium closed will not 
grow afterwards, and absent or defective parts will not de- 
velop; that even cases with a clear history of premature ossifi- 
cation are not, or very doubtfully, benefited ; that, finally, 
the operation undertaken for the purpose of enlarging the 
cranial cavity has the opposite effect, as is proved by the ex- 
perience of Van der Veer and Hun, also b} r a case reported 
and drawn by Bourneville, and, finally, by the skull, belonging 
to B. Sachs, of a child operated upon twice in the course of 
sixty-seven days by A. Gerstcr. It exhibits a mass of hard 
tissue proliferating into the cranial cavity along the whole 
wound made in the first operation. I trust, therefore, that 
the days of uncalled for craniotomy and craniectomy are 
numbered. 

Starr observed, in 1889, a total of 270 brain tumors in 
children. Of these, 152 were tubercles, 37 gliomata, 34 sar- 
comata, 5 gliosarcomata, 30 echinococci, cysticerci, and cysts, 
10 carcinomata, and 2 gummata. The carcinomata were 
mostly secondary, the gliomata and sarcomata primary. Forty 
of the two hundred and seventy were superficial, and in six- 
teen of the forty their localities could be distinctly diagnosti- 
cated. Therefore, trephining and operations on the substance 
of the brain for tumors will never be numerous. Their diag- 
nosis is not always easily made, and that of the locality af- 
fected is beset with still more difficulty. Gliomata are but 
rarely near the surface; solitary tubercles are sometimes 
found in the gray substance of the brain, but more frequently 
in the corpora striata or thalami optici. In many more in- 
stances an operation will be required because of tumors origi- 
nating in the cranium or its periosteum and encroaching 
upon the brain ; they are mostly sarcomata, fibro- sarcomata, 



332 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

or osteomata. One of the last mentioned I have removed. 
A cyst of the dura mater, resulting from hemorrhage, was suc- 
cessfully removed in the service of Dr. Henry Hun, at Al- 
bany, followed by marked improvement of the child's idiocy 
and convulsibility. 

The simplest form of cerebral meningitis is that which re- 
sults from insolation and mental emotions and exertions. 
Frights (especially protracted fears) and overstudy are fre- 
quent causes. So is trauma, which, however, is liable to pro- 
duce the purulent form. In pneumonia, particularly of the 
upper lobes, it is not uncommon ; less frequent in typhoid 
fever, more so in the septic diseases of the newly-born, where, 
however, it is liable to form part of the general pysemic condi- 
tion. An antiphlogistic course of treatment is here indicated, 
if anywhere. The hair should be cropped short; the head 
must rest on a cool pillow and be placed high. Calomel 
at first in purgative, later in smaller doses. As the mer- 
curial treatment is to be continued, a solution of potassic 
chlorate ought to be applied frequently to the gnms and 
mouth. The heat of the head and the local inflammation 
must be fought by cautious cold applications, according to 
the directions formerly given (p. 88), and by leeches applied 
to the nasal septum or to the mastoid processes, also by cup- 
ping to the neck and shoulders ; coma by cold affusions to 
the head and hot bathing of the rest of the body. Great 
restlessness, sleeplessness, and general excitation demand warm 
bathing, bromides in generous doses, from one to ten grammes 
(fifteen to one hundred and fifty grains) a day, chloral, and 
codeine. After the first invasion and the period of high 
fever have been successfully dealt with by calomel and a 
few large, afterwards moderate, doses of digitalis, the time 
for iodide of potassium (one to five grammes daily) has ar- 
rived, also for vesicatories to the neck and behind the ears. 
In regard to the latter, however, it is always well to be care- 



DISEASES OF THE NERVOUS SYSTEM. 383 

fill, for cantharides are the sworn enemies of the kidneys. 
The iodides must be continued a long time. Of the robo- 
rants to be given during convalescence, iron ought to be the 
last one selected. 

It is not always easy to diagnosticate between a fully- de- 
veloped meningitis and a hypersemia resulting from similar 
causes, — viz., overexertion, emotion, insolation, and the con- 
tinued effect of overheating and stimulating diet. The con- 
tinuation of the treatment depends on the persistence of the 
symptoms. Quite frequently a warm or hot mustard bath, 
with temporary applications of ice to the head, repeated hot 
foot-baths, sinapisms to the neck, an erect posture in bed, 
a calomel purgative (with or without local depletion), and 
occasional counter-irritation by derivant enemata (vinegar 1, 
water 5-6) will suffice. The passive hyperemia, however, 
complicated with and depending on general and local cere- 
bral anaemia (occasionally even thrombosis of small vessels) 
and that which is caused by the rapid inanition produced 
by the different forms of acute and exhausting intestinal dis- 
charges require an altogether different treatment. In place 
of the antiphlogistic treatment, stimulation is indicated. Still, 
caffeine and alcohol are to be avoided during the worst stage ; 
camphor, ammonium carbonate, and musk will answer better. 
Food and medicines are to be regulated by the requirements 
of the follicular or other enteritis, and water must be sup- 
plied in ample quantities. When there is vomiting and 
diarrhoea is persistent, neither the stomach nor the rectum will 
accept it. In these cases the only salvation may be in copious 
(pint or quart) subcutaneous infusions of warm and sterilized 
salt-water solution (water 1000, table salt 6-7, sodium car- 
bonate 10-12). 

TJiromboses from other causes are treated on the same prin- 
ciples. Debility and paralysis require such stimulants and 
irritants as the brain will tolerate. Embolisms, with their sec- 



384 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

ondary conditions of irritation and inflammation, should be 
treated according to the rules detailed above, and will require 
ice, purgatives, warm bathing, and iodides, with or without 
bromides. The resultant paralysis demands massage, elec- 
tricity, strychnia, and mineral baths such as St. Catharines 
or Kreuznach. Chronic remnants of an inflammatory dis- 
order, no matter from what cause, may be benefited, even 
after a long time, by a protracted course of treatment with 
iodide of potassium, or with mercurials, or both together, or 
alternating. 

Ergot is useless in these cases of intra-cranial hyperemia ; 
it does not have the favorable effect often following its use in 
similar changes in the spinal canal. 

Tubercular meningitis is not always fatal, though the diag- 
nosis permit of no doubt. The latter, however, is mostly 
made at a time when the prognosis is very ominous. Biedert 
had an opportunity to make an autopsy on a patient treated 
for tubercular meningitis, death resulting from another dis- 
ease. He found old meningeal tubercles. Still, many of the 
recoveries reported — mainly for the purpose of proving the 
efficacy of specific treatments (tartar emetic and iodoform 
ointments, etc.) — are of doubtful character. I have also seen 
recoveries from what I diagnosticated as tubercular menin- 
gitis. One died afterwards of necrosis of the cranial bones, 
occasioned by my tartar emetic ointment. Another case, that 
recovered thirty years ago, is still alive in an insane asylum ; 
he has never been normal, mentally, since I discharged him 
" cured." From what little I have said it is evident that a 
preventive treatment only may be expected to do good, if 
anything will. Infants and children of scrofulous or tu- 
berculous families must be brought up with unusual care. 
Congestion of the brain, caused by feather pillows, exposure 
to the sun, hot rooms, coffee, tea, and alcohol, physical and 
mental overexertion, must be guarded against. Constipation 



DISEASES OF THE NERVOUS SYSTEM. 385 

must be overcome. Eczema and other eruptions of the sur- 
face should be slowly healed, but they must be healed. Their 
presence is a constant source of danger, both by reason of 
the opportunities afforded for a direct invasion of microbes, 
and of the irritation and swelling of lymph bodies. These, 
when found, must be removed by internal treatment, mas- 
sage, ointments (green soap, iodide-lanolin mixtures), or enu- 
cleation. Nasal catarrh should be immediately relieved ; its 
persistence is a cause of " scrofulous glands" and, possibly, of 
secondary tuberculosis ; also of direct invasion of germs 
through the patent orifices of the lymph- vessels at the base 
of the cranium and the extra-dural tissue. The best general 
preventive treatment of infants and children with a predispo- 
sition to tubercular meningitis, rendered probable by hereditary 
taint and by suspicious symptoms, consists, in my opinion, in 
the regulation of the diet and hygiene : animal food mostly, 
daily cool or cold bathing with vigorous friction, open win- 
dows, exercise, cod-liver oil during the cool and cold months, 
arsenic in regular small doses, and pure guaiacol (or the car- 
bonate of guaiacol) for many months in succession through 
a course of years. 

When the disease is fully recognized, constipation must be 
overcome ; the first drug to be used for that purpose must be, 
or contain, calomel. It may be repeated from time to time, 
provided the regular use of iodide of potassium does not con- 
traindicate it. The latter ought to be given in large doses 
through (nearly) the whole duration of the illness. Tubercu- 
lar meningitis both permits and demands large doses, — from 
one to three drachms (five to twelve grammes) daily. Mercury 
is indicated. Calomel and iodide of potassium being in- 
compatible, the bichloride should be given, or mercurial oint- 
ments used instead. Cardiac stimulants may be employed to 
advantage from the beginning, the circulation being defective 
on account of the undue irritation of the pneumogastric nerve. 

25 



386 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

Strophanthus and strychnia in very small doses will probably 
act better than digitalis. Caffeine and alcohol must be care- 
fully avoided. Chloral will act well when headache is severe 
and a tendency to convulsions exhibits itself. To combat the 
latter the inhalation of chloroform cannot be avoided ; nor 
can morphia altogether, when the pain is excessive. Antipy- 
retics are not indicated in the beginning, when the temperature 
is low ; during the last few days, when it rises previous to 
death, they are useless. With tartar emetic ointments applied 
on the closely shaved head I have had ample experience, and 
shall not employ them again. My experience with iodoform 
ointments (1 : 5-10) is but small, and my confidence in their 
efficacy less. Vesicatories may do harm by annoying and irri- 
tating the patients ; I expect more derivative action from 
keeping the bowels open and the body sufficiently covered with 
clothing. Leeches are seldom useful, except when conjunctival 
injection and local heat of the head become apparent at an early 
date. Otherwise, symptomatic treatment is all that can be 
advised. Unusually severe vomiting in the beginning may 
require ice pills and mild doses of an opiate, or cocaine, per- 
haps tincture of iodine in one-quarter- to one-half-drop doses, 
or arsenous acid, 3-^ to 3-^ grain (^- J- milligramme), from 
four to ten times a day. Ice applications are useless, for the 
temperature is low, the local hypersemia mostly passive, and 
the tolerance of ice in small children easily exhausted. 

To what extent the operative treatment by trephining and 
draining will prove successful remains to be seen. There 
are but few cases of tubercular meningitis not complicated 
with general miliary tuberculosis; thus the prognosis of 
operative interference is not at all promising. Besides, the 
cranial cannot be compared with the peritoneal cavity, which 
is known to be favorably influenced by the performance of a 
laparotomy. Peritoneal tuberculosis is very apt to be isolated 
and uncomplicated, its secreting surface of a different char- 



DISEASES OF THE NERVOUS SYSTEM. 387 

acter, and drainage easier. Quincke, Fiirbringer, Caille, and 
others have tapped the spinal canal between the third and 
fourth lumbar vertebrae. The operation has resulted in facili- 
tating a diagnosis (by proving the presence of bacilli in the 
cerebro-spinal liquor), in temporarily relieving symptoms, but 
never in a cure. 

The prognosis in, and the results of treatment of, chronic 
hydrocephalus depend on its nature. When it is congenital, 
no matter whether internal or external, whether the result of 
a foetal inflammation or of an arrest of development, the 
morbid processes leading to it are so serious as to render the 
outcome of treatment — though it do not prove fatal — very 
problematic. Substantial changes of the original brain-sub- 
stance cannot be remedied by the removal of fluid. Nor is it 
probable, or rather possible, that the cerebral atrophy produced 
by permanent intra-cerebral pressure can be overcome by at- 
tempts at relieving hydrocephalus. The chances are better 
when chronic hydrocephalus is the result of a post-natal men- 
ingitis. But even in these cases, while the recoveries — I 
mean anatomical recoveries — from the secondary effusion are 
more numerous, the inflammatory alterations both in me- 
ninges and brain are such as either to predispose to future 
meningitis, or to so alter both the physical and mental func- 
tions of the cranial contents as to render the result either 
very doubtful or far from desirable. Our prisons and lunatic 
and idiot asylums tell the tales. The chances of hydroceph- 
alic patients are best when the disease is the result of chronic 
hypersemia, — for instance, in craniotabes. Children with a 
slight amount of hydrocephalic effusion are always apt to get 
entirely well under proper antirhachitical treatment (fresh air, 
animal food, phosphorus, iron, etc.), and even large amounts 
of fluids are absorbable, with restitution of the brain and its 
functions, in a certain percentage of cases. 

After all, it is evident that iodides, mercurials, vesicatories, 



388 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

diaphoretics, diuretics, and purgatives are useless in con- 
genital hydrocephalus. In the other forms the diagnostic and 
therapeutical skill of the practitioner will make the required 
selection, as far as indicated. Should the head grow rapidly, 
the prognosis is bad. In these cases even compression will do 
but little, inasmuch as compression of the increasing fluid 
will also compress the brain. In less progressive cases the 
application of rubber bandages or caps, also adhesive straps, 
may do some good. They should not be omitted in all cases 
where puncture is resorted to, provided the cranium is still 
compressible. Indeed, in almost all the cases on which it was 
performed the children were quite young and no ossification 
of the sutures had taken place. Therefore the case success- 
fully operated upon by Rehn, of Frankfort, Germany (with 
repeated punctures), — that of a girl of twelve years, who was 
presented (alive) before the German Congress for Internal 
Medicine of 1886, — may be considered very exceptional. 

Punctures of the hydrocephalic cranium were made in an- 
tiquity, but, like mauy other experiences of Hippocrates, were 
forgotten. It was not until this century that observations of 
recoveries were made after the intra-cranial fluids had found a 
spontaneous or traumatic outlet. Hofling published a case 
(1828) of recovery after a complicated fracture of the frontal 
bones and a discharge extending over days ; Greatgood (1828) 
one after an injury produced by a nail; Haase (1818) one of 
spontaneous perforation. Huguenin collected six cases of 
recovery after a discharge through the nose (or ear) had been 
established. Punctures have been made in great numbers ; 
many more, certainly, than have reached the eyes of the medi- 
cal public. It can, however, be easily understood that very 
probably not a single case of recovery has taken place but has 
been published. Indeed, the publications are mostly made 
very soon after the operation or operations are performed. 
Thus, when Beely collected twenty-seven cases of recovery 



DISEASES OF THE NERVOUS SYSTEM. 389 

after puncture (two of which were combined with tincture of 
iodine injections), he expressly stated that only eight of them 
had been under observation a year or more. Altogether, it 
may be more human than, unfortunately, scientific to pride 
oneself on one's results, particularly when these results prove 
of benefit to mankind. Thus, Conquest reports " ten cures" 
out of nineteen cases operated upon by himself. West, than 
whom there is no critic more learned, wise, and incorruptible, 
collected sixty-five cases with (alleged) " sixteen recoveries," 
which he, however, reduced to from three to perhaps five. 
Battersby came to the conclusion that probably there was one 
recovery in fourteen cases on which the operation was per- 
formed. But from my previous remarks, referring to the se- 
verity of the original lesion and to the results of the fluid 
present either outside or inside the brain, it is easily understood 
that I cannot look upon the result of the operation as any- 
thing like as favorable as is claimed. Still, there are many 
cases in which it must not be omitted, together with general 
treatment. Among the remedies I value most highly here or 
wherever tissue-building is a main object is phosphorus. It 
may be alternated or combined with iodides, digitalis, iron, 
or arsenic, according to circumstances. 

The puncture must be made over the large fontanel, about 
one centimetre or more (half an inch) from the median line ; 
vertical when the lateral ventricle is to be reached, diagonal 
when the hydrocephalus is external. It is best not to remove 
much fluid the first time; from fifty to sixty cubic centimetres 
(Sii) will suffice. As a rule, there is but little reaction, and 
the operation may be repeated within a few days or a week. 
During the operation and after it compression must be made 
to prevent hyperemia, hemorrhage, and rapid re-effusion. In 
cases of external hydrocephalus a mild injection of iodine, or 
of iodide of potassium and water (" Lugol"), may be given to 
suppress secretion. It will take very numerous observations, 



390 THEKAPEUTICS OF INFANCY AND CHILDHOOD. 

however, during the next fifty years to determine to what 
extent all these attempts at suppressing secretion and at fa- 
cilitating meningeal adhesions are valuable in the interest of 
families or of mankind in general. 

A number of chronic degenerations of the brain, both gen- 
eral and local, are the result of inflammatory processes. If 
they be prenatal, the prognosis is very bad ; if acquired 
after birth, the nearer the beginning of treatment to their 
origin the better the possible result. Such conditions are 
disseminated sclerosis, also the infantile spastic hemiplegia de- 
pending on encephalitis, and bulbar paralysis. The general 
indications for treatment are the same. In acute exacerbations, 
depletion, ice, and laxatives will be required ; bulbar paralysis 
may often cfemand a local application of ice. The chronic 
condition requires the different forms of electrical and gal- 
vanic treatment, iodides, mercurials, and warm bathing. In 
all such cases the indications are pronounced enough, but the 
results mostly negative. 

Meningocele and encephalocele (hernia of the brain) are but 
rarely amenable to a successful treatment. When they are 
small, the protruding contents may be retained by a properly 
fitting appliance of lead or leather or rubber, until the abnor- 
mal aperture has had time to close. This process may be 
accelerated by the administration of phosphorus (ol. phos- 
phoratum or elixir phosphori), of which the newly-born may 
take at the rate of one-third of a milligrame daily (gr. y-g-o). 
When larger and irreducible, the tumefaction has been caught in 
a clamp and punctured, or removed altogether. In some cases 
the clamp was allowed to remain, in others it was removed ; 
in the latter the wound was sutured. Similar treatment has 
been resorted to in a few cases of meningocele spuria, which 
results from fissures of the cranium induced by forceps oper- 
ation, by fall or other trauma, by caries, or by syphilis. 

Epidemic cerebrospinal meningitis requires absolute rest of 






DISEASES OF THE NERVOUS SYSTEM. 391 

both mind and body from the very beginning. Though the 
prognosis be much better than in the different forms of cere- 
bral meningitis, the long duration of the disease endangers the 
result. Noise and glaring light must be excluded, no muscu- 
lar exertion permitted, the neck supported ; in bad cases of 
hyperesthesia the bedclothing should not be permitted to touch 
the body. The urinary bladder requires watching. Leeches 
applied to the painful spine will do some good in the very early 
stages ; an ice bladder, on which the neck must be made to 
rest comfortably, and another one to the occiput, and a purga- 
tive dose of calomel ought to usher in the remedial treat- 
ment. Unless contraindicated by great sensitiveness, mercurial 
ointment externally and iodide of potassium internally are 
expected to do good. The latter is generally given in too 
small doses, and thus misses its effect ; from three to five 
grammes (grs. 45 to 80) daily, and more, are easily tolerated, 
and are required by a child of five years. Bromides will 
quiet excessive restlessness (doses of 1-4 grammes a day) ; 
there are, however, very few cases but will be greatly benefited 
by sufficient doses of opiates, or chloral, to insure comfort 
and sleep. Sinapisms should be applied for a few minutes at 
a time, and frequently repeated ; in the later stages a vesicatory 
over the cervical part of the spine is indicated. I am not 
pleased with the effects of tincture of iodine or iodoform oint- 
ments. Salicylic acid and salicylates have been praised ; but 
I am afraid that the cases in which their good effects were ob- 
served were those of mistaken diagnoses, for, indeed, rheuma- 
tism of both the muscles and the meninges has been taken for 
different forms — even the very gravest — of meningitis. The 
after-effects of the disease, particularly paralysis and contrac- 
tures, are difficult to handle ; their treatment does not call for 
any special measures dictated by the original disease. Deaf- 
ness is liable to prove permanent, in spite of hydrotherapy, 
diaphoresis, and electro-therapy. The actual cautery has been 



392 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

used extensively. In the acute stage of the disease it is use- 
less or harmful ; in the chronic it has been known to do good, 
and may be applied regularly. 

The modern progress of our acquaintance with the etiology 
of infectious diseases adds to our preventive powers. H. 
Jaeger (Zeitsch.j. Hyg. u. Infect. , xix. p. 351) asserts that sixty 
per cent, of all cases of cerebro-spinal meningitis are connected 
with or dependent on the pneumococcus (and diplococcus in- 
tra-cellularis ?). This explains the frequent complication with 
pneumonia. Thus, the nasal secretion in which the diplococ- 
cus is of frequent occurrence requires particular attention. 
Indeed, as early as 1888 the Prussian government ordered 
the disinfection of linen — mainly handkerchiefs — from this 
point of view. For the same reason the violent aspiration of 
the naso- pharyngeal secretion, for the purpose of expectora- 
tion, may prove unfortunate for the individual and, second- 
arily, for the community. 

The general rules for the treatment of diseases of the 
organs contained in the spinal canal are almost identical with 
those detailed in reference to the brain and meninges. With 
the exception of rare cases of pseudoplasm, the changes oc- 
curring in the spinal cord and its meninges depend on anom- 
alies of circulation, or on some form of inflammatory process, 
either in an acute or a chronic state. To the latter class be- 
long the final and persistent lesions of spinal, pachy-, and 
lepto-meningitis, transverse myelitis, poliomyelitis, lateral and 
amyotrophic lateral sclerosis, paramyoclonus, and tabes. Before 
entering upon a course of treatment, it is of the greatest im- 
portance to study the etiology of an individual case ; a disease 
of the bone, or tuberculosis, or syphilis must be known before 
it can be effectually treated. Nor is it superfluous to omit the 
exact diagnosis of those ailments which are more and more 
supposed to be of an infectious nature and bacteric origin, 
such as Landry's paralysis and poliomyelitis ; for the time 



DISEASES OF THE NERVOUS SYSTEM. 393 

may come, even during our lives, when an extensive anti- 
infectious, antibacteric, antitoxic treatment or preventive im- 
munization will be among the accomplishments of modern 
therapeutics. 

In every case of acute disease of the spinal cord or its 
meninges absolute rest is required. But the patient, to avoid 
overheating and hypostasis, must not be kept on his back 
constantly, or most of the time, and not on feather beds or 
pillows. Quilts covered with linen or cotton sheets, air mat- 
tresses, or water beds are often absolute necessities. When the 
acute disease can be localized, as mostly it can, cold water, 
ice-water, the ice bag, with now and then an ether spray, or 
local depletion by cups or leeches, are indicated. Vesicatories 
or tincture of iodine ought to be avoided in this stage, because 
of their irritating and annoying effects. Purgatives are re- 
quired on general principles, — calomel (and) or salines. Now 
and then a mustard bath, quite hot, will act well as a derivant. 
The indications for digitalis (or other heart regulators and 
invigorators) are frequent ; direct antipyretics are seldom re- 
quired. Quinine acts better here than in diseases of the brain, 
where it appears to give rise to occasional congestions. To 
influence the spinal circulation in acute and subacute diseases, 
ergot (useless in cerebral diseases) holds a high rank ; the fluid 
extract may be given in doses amounting for the day to from 
one to eight or ten grammes in the beginning, later less, ac- 
cording to age. Its indication does not cease until the stage 
of chronicity, with anaemia, contraction, and incipient atrophy 
of blood-vessels. Iodide of potassium is indicated early on 
account of its influence on circulation, and later for its absorb- 
ent effect. The difficulty in handling very old cases is due 
to the permanency of the local lesions which result from the 
solidification and cicatrization of the new cell proliferations. 
Nor are the difficulties in this respect any less, with the excep- 
tion of some syphilitic cases, in regard to mercury. The 



394 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

sooner and the more persistently, either internally or exter- 
nally, these remedies are employed, either simultaneously or 
alternatively, the better will be their gradual effect. The bug- 
bear of salivation is no longer feared, since it has become more 
widely known that the younger the patient the better will 
he bear mercury. Galvanism and the electro-magnetic cur- 
rent are used on general principles, as mentioned before. 
Neither should be employed at an early stage. The former 
requires large electrodes, well salted, to reach the cord ; the 
direction of the current does not appear to make much, if 
any, difference. Sessions of from six to ten minutes, the cur- 
rent being inverted once or twice during that time, once or 
twice daily, are all that are demanded. The interrupted current 
is employed later to stimulate the muscular action, and should 
be used locally with small or more generally with large elec- 
trodes, or in the bath. Anaesthesia may require the application 
of the metal brush. Warm bathing is often attended by 
very good effects, due to its influence on circulation and the 
surface temperature. A bath may last minutes or hours ; the 
latter mainly in secondary contractures, which may also require 
tenotomies. In these cases hot sand baths have been used ex- 
tensively in Europe, particularly where the fear of water has 
not yet begun to wane from the minds of the masses. Their 
usefulness consists mainly in the invariability of the tempera- 
ture, which requires less attention and watching than a warm 
water bath. In chronic cases ointments have been exten- 
sively used. Still, very few substances can be rubbed through 
the epidermis and cutis; indeed, hardly any except iodide 
of potassium (in glycerin, better still in lanolin) and mercury 
(ointment and oleate). Application to the spinal column is 
of no advantage ; it is better to select the usual places where 
the skin is thin and the lymphatics are near and numerous, — 
viz., the inner aspect of the extremities. Here also the actual 
cautery has been found beneficial, together with the mineral 



DISEASES OF THE NERVOUS SYSTEM. 395 

springs containing salts and iodine (St. Catherine, Kreuznach, 
Oeynhausen, Nauheim). 

In many of both the acute and the chronic cases a symp- 
tomatic treatment cannot be avoided. Pain must be lulled. 
Now and then the anode (positive pole) of a mild galvanic 
current will have some effect; sometimes the local applica- 
tion of chloroform ointments or chloroform vapor in cotton, 
an ether spray, a menthol stick, or menthol in a ten-per-cent. 
alcoholic solution w T ill do good. If not, hyoscine, chloral 
hydrate, croton chloral hydrate, opiates (internally or sub- 
cutaneously), or hot fomentations are required; for there is 
no greater enemy of the sick than pain, and no greater bliss 
and gain than rest. Other symptomatic treatment may be 
required for the motory and trophic paralyses resulting from 
a number of spinal-cord diseases, such as paralysis of the 
bladder, of the intestines, of the sphincters, and bed-sores. 
The latter are very ominous, and the ointments of bismuth, 
or tannin, or balsam of Peru, though they be indicated and 
locally useful, will not defer very long the final termination. 
Paralysis of the bladder is said to be benefited by local inter- 
nal electrization ; it is benefited by ice-cold injections ; its sec- 
ondary cystitis is certainly improved by plain or medicated 
warm irrigation. Paralytic constipation requires physostigma 
and regular enemata. All of these forms of paralysis will 
be more benefited by the subcutaneous than by the internal 
administration of the sulphate of strychnia. 

Suspension has been practised for several years in some of 
the chronic diseases of the spinal cord, mainly in tabes, which, 
fortunately, is rare among children. It may again become 
fashionable in another generation. Operative extension of 
nerves is occasionally useful in contractures depending on 
cicatrization. 

Acute poliomyelitis (spinal paralysis, essential paralysis, 
" dental" (!) paralysis, infantile paralysis), as the initial stage 






396 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

may differ both in its onset and in its symptoms, may require 
different measures at first. Some cases exhibit a high fever, 
great excitement and prostration, even cerebral symptoms. 
The majority, however, come on suddenly, without fever and 
without premonitory symptoms. The former class requires 
antipyretics and the necessary attention to cerebral and other 
urgent symptoms ; much more can hardly be done, because in 
most cases of this class the diagnosis will probably not be 
made at first, with the exception of those in which it is 
assured by local pain and the observation of the paralysis. 
These latter are the cases in which local applications of ice 
may prove beneficial. 

Every case, whether feverish or afebrile, requires absolute 
rest. The few which are suspected of originating from rheu- 
matism, or those which are complicated with peripheral neu- 
ritis, should be treated by salicylates, and locally by warm 
applications or fomentations. All the rest will do better 
with cold applications — ice water, ice-bladder, cold water — 
continued for some time, but with interruptions. Depletion 
by means of leeches, or by cupping, is often indicated, par- 
ticularly in such cases as exhibit local pain. I feel certain 
that a purgative in the beginning (calomel, salines) will do 
good ; so will ergot ; the equivalent of from one to three 
grammes or more may be given daily, either as extractum 
ergotse or as extractum ergotse fluidum. It may be accom- 
panied by a few drops of the tincture of belladonna. As 
early as possible — that is, as soon as the necessity of absolute 
rest will permit of inunctions being made — mercurial oint- 
ment (on the first day or days the oleate) may be used, and 
the internal administration of iodide of potassium commenced 
at once. Both may be continued — particularly the latter — for 
several weeks ; the dose should be smaller than in cerebral 
meningitis, half a gramme to one gramme daily being suffi- 
cient. Tincture of iodine modified by the addition of alcohol, 



DISEASES OF THE NERVOUS SYSTEM. 397 

or sinapisms frequently applied for a few minutes at a time 
may be used with advantage. 

The rapid improvement during the first week after the onset 
of the disease, and the slow convalescence of the few months 
before the residual (mostly local) paralysis becomes final, having 
been established, the indications for treatment will change. 
Congestion and dilatation of blood-vessels give way to anaemia 
and contraction, and in place of belladonna and ergot, strych- 
nia must be given; at first, perhaps, internally. It may be 
beneficial when so administered, but hypodermically it will 
act better. I cannot agree with Gowers, who claims that it 
is probably " never either 'necessary or desirable to give it by 
hypodermic injection in this disease." Several times a day, 
for weeks in succession, the cold shower-bath applied one or 
two minutes to the back, followed by lively friction, will con- 
tribute to the stimulation of the spinal circulation. 

The rapid waste of the paralyzed muscles requires local 
stimulation. Frictions with oil, vaseline, alcohol and water, 
tepid water, or hot water must be made several times a day. 
Where the surface circulation is still fair, cold water may be 
preferable. Passive movement must take the place of active 
exercise when the latter is impossible. The faradic current 
will stimulate and may improve whatever there is left of 
contractility. Should it become totally inactive, the reversed 
galvanic current may take its place for the purpose of exer- 
cising the muscles. Otherwise the galvanic continuous cur- 
rent is eminently the nerve and blood-vessel stimulant, and 
must be constantly used to keep up the circulation and thereby 
the nutrition of the degenerating tissues. It is best applied 
through large electrodes, and should be made to ascend and 
descend alternatively. Sessions of from six to ten minutes, 
one or two every day, are sufficient, but they must be con- 
tinued a long time. I know that limbs which had remained 
unchanged in their atrophy and uselessness for years im- 



398 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

proved under patient galvanic handling, when persisted in 
for a long time. 

Mechanical appliances will prove useful. The arm must 
be so supported as to render the paralytic slipping out of the 
socket of the paralyzed humerus an impossibility. The rare 
cases of dorsal paralysis require a jacket or a properly fitting 
corset. The paralyzed (mostly extensor) muscles of the lower 
extremities demand elastic bands, so as to counteract the con- 
traction of the antagonistic flexors and thus facilitate walking. 
Meanwhile the remedial agents mentioned before must be con- 
tinued. Strychnia will always do good, and phosphorus will 
act both as a nerve stimulant and as a tissue builder. It may 
be given to a child a year old in doses of from half a milli- 
gramme (half a teaspoonful of the elixir of phosphorus of 
the United States Pharmacopoeia) to three-fourths of a milli- 
gramme daily. To expect an improvement of nutrition by 
ligating the paralyzed limb is a grave mistake. That pro- 
cedure will tumefy, but not nourish, the constricted part. 

Consecutive club-foot requires the employment of proper 
orthopaedic apparatuses at as early a time as is judicious, to 
prevent an unnecessary degree of anemia, atrophy, and loss 
of length. To avoid the necessity of such mechanical aids, 
an operation has been performed — arthrodesis — for the pur- 
pose of anchylosing the upper ankle-joint, in some cases also 
the talo-calcaneal joint. The after-treatment consists in the 
use of a plaster-of-Paris bandage, which should be carried 
three months by children under ten years, six weeks by adults. 
The highest degree of tendon contraction may require ex- 
tirpation of the talus, but is usually overcome by tenotomies. 
After recovery a snug shoe must be worn. 

Circumcision has been performed on children affected with 
poliomyelitis, without any justification either in theory or 
practice. 

The forms of hydrorrhachis (spina bifida) are various, and 



DISEASES OF THE NEKVOUS SYSTEM. 399 

extensive arrests of development or by secondary changes in 
the treatment differs accordingly. Cases accompanied by other 
the lower extremities do not respond favorably to treatment. 
Those rare ones which are complicated with superjacent tumors 
(mostly lipomata) or with hypertrichosis (very rare) must be 
carefully watched, for careless operations on what were con- 
sidered uncomplicated pseudoplasms have proved fatal. Such 
as are of central origin, the substance of the posterior horns 
with the nerve-roots spreading over the sac, are of grave 
prognosis. Spontaneous bursting of the sac must be guarded 
against, for much loss of cerebro- spinal liquor is apt to ter- 
minate fatally in a very short time. Puncture may be resorted 
to and repeated, a fine needle being used. After each punct- 
ure pressure ought to be applied to prevent rapid filling up. 
A few cases — small ones of simple meningocele — have been 
known to get well in this w T ay. Or, after the puncture, iodine 
may be injected. Morton's formula — iodine 1 part, potassic 
iodide 3 parts, and glycerin 48 parts — has been very successful 
in his hands and in those of others. Favorable cases have 
been successfully treated by the clamp, suturing, and gentle 
compression, and bad cases by extirpation of the sac and util- 
ization of the periosteum of the patient. Robson transplanted 
that of a rabbit in 1883. 

Nicolaier's discovery of the bacillus of tetanus in 1885, 
and its pure culture by Kitasato in 1889, together with the 
progress made in immunization and antitoxic treatment gener- 
ally, add to our hopes of the curability of tetanus. Immuni- 
zation against tetanus has been proved in mice, and recovery 
has taken place when serum was injected five hours after the 
introduction of the culture. But it is true that a hundred 
times the amount of serum was required in an animal infected 
only a quarter of an hour before, as compared with the amount 
required before infection was accomplished ; it is also true that 
no absolutely certain and indubitable success has thus far been 



400 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

proved, but there can be no reasonable doubt as to the results 
of antitoxic methods of treatment shortly to be developed. 
Still, the experiments on mice do not prove the efficacy of 
the serum in the tetanus of the human animal, and no case 
of tetanus in the latter is on record as having been cured by 
its antitoxin. The eifect of heavy doses of the bromides, of 
chloral, of curare, and of opium is undoubted. Most of the 
cases of tetanus in the newly-born and in the adult that I 
have seen get well did so under chloral and occasional doses 
of opium. Carefully, but early, must the doses of chloral hy- 
drate be increased. In some instances they were incredibly large. 

It is probable that those cases of tetanus which are un- 
doubtedly of bacillary origin are least amenable to treatment. 
Such as are of rheumatic or traumatic origin, and even such 
as result from throat inflammations, are perhaps most easily 
influenced by remedies. 

The treatment of eclampsia depends on its causes. Repeated 
attacks may be the results of identical causes, — for instance, 
feverishness, intestinal disturbances, and emotions, — but they 
suggest the existence of epilepsy. Indeed, a single eclamptic 
attack cannot be distinguished from an isolated epileptic 
seizure. According to the various causes to which eclamptic 
convulsions may be due, the best preventives are regulation 
of the diet, of the bowels, and the removal of worms ; the 
withholding of alcohol, coffee, tea, and improper foods; the 
watching of every kind of fever, from a simple catarrh to an 
inflammatory or infectious disease. In households where there 
are babies known to be subject to eclampsia the clinical ther- 
mometer is indispensable. Catarrhal fever, intermittent fever, 
pneumonia, otitis, meningitis, and acute eruptive diseases are 
often ushered in by a convulsion. Tight bandaging, renal 
calculus, and splinters in the skin are to be suspected when 
no other cause is readily found. A normal dentition never 
produces a convulsion, and "difficult dentition" as a cause of 



DISEASES OF THE NEKVOUS SYSTEM. 401 

convulsion is among the affections which are as rare as they 
are too readily diagnosticated.* The frequency of the habit 
of lancing the gums, to which many practitioners are still 
addicted, proves the frequent absence of diagnoses and the 
readiness with which tribute is paid to the prejudices of past 
centuries and to those of the female population. Cranial and 
encephalic rhachitis, with or without laryngismus stridulus, 
is often attended by convulsions, and requires antirhachitical 
treatment. 

The habit of regularly administering bromides to infants 
who have convulsions is a bad one. As a regular medication 
they ought to be reserved for epilepsy. The attack demands 
the removal of the cause. Irrigation of the stomach, or an 
emetic ; irrigation of the bowels with water, soap and water, 
oil, turpentine, assafcetida, and a purgative (calomel with or 
without an antifermentative, such as resorcin or salol, fol- 
lowed or not by castor oil) ; the proper use of a warm bath ; 
a cold pack frequently repeated, with ice to the head and heat 
to the feet; the timely administration — in an urgent case 
antipyrin under the skin — of an antipyretic ; chloral hydrate 
internally or by the rectum ; inhalations of chloroform to 
shorten the attack, — all suggest themselves as most promising. 
The latter ought not to be deferred, for any moment of a 
violent convulsion may occasion a cerebral hemorrhage with 
its dire results to life, or body, or mind. Sinapisms to the 
neck and to the extremities have often been recommended, but 
besides the possible after-effect of annoying and irritating the 
infant suffering from a vulnerable nervous system, they cannot 
be expected to have much, or sufficient, derivative action. To 

* Kassowitz comes to the same conclusion, as, indeed, did many before 
him. He quotes the literature copiously, also the book of Fleischmann, 
who quotes me. But, probably because my results in 1862 were so very 
identical with those of Kassowitz in 1893, it was not thought necessary to 
take notice of my " Dentition and its Derangements," New York, 1862. 

26 



402 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

quiet the irritability persisting after an attack, chloral hydrate 
with or without a bromide, or repeated small doses of codeine 
or extract of opium, or the camphorated tincture of opium 
may be administered. 

The causes of chorea minor — St. Vitus's dance — are either 
anatomical changes (some of them improvable, some incura- 
ble) or functional disturbances. Therefore the treatment 
should vary according to the etiology, but hardly a case will 
act well without attention to the functional treatment. Indeed, 
some forms of the latter are almost of a specific character. 
Prevention is indicated when the patient is of a neurotic con- 
stitution ; the descendant of a neurotic family ; when suffering 
from digestive or genito-urinary disorders (masturbation), per- 
haps supplied with alcohol in more than medicinal doses, or 
if he has rheumatism or heart-disease. Capillary embolisms, 
cysts, tubercles, apoplexies, and exudative changes in the 
nerve-centres, particularly the brain, are not subject to pre- 
ventive measures. Demme observed a case depending on a 
fissure of the anus ; it admitted of direct treatment ; Solt- 
mann a chorea of the left side after traumatic depression 
of the right parietal bone; others report cases depending on 
shrinking cicatrices and on neuritis. I have observed a marked 
case of acute chorea which depended on spinal meningitis of 
the cervical portion. In this case ice, local depletion, pur- 
gatives, and ergot were the successful remedies. (Seguin's 
" Clinical Lectures/' vol. i., 1872, second lecture.) In the 
American Journal of the Medical Sciences, April, 188G, and 
in the " Festschrift zum 70sten Geburtstag von Professor 
Henoch," Berlin, 1890, I published observations of partly 
local, partly general chorea depending on nasal reflexes due 
to catarrhal and inflammatory changes and to polypi. In all 
these cases the treatment and cure of diseases of the nose and 
naso-pharyngeal cavity are demanded as preliminary to the 
successful treatment of St. Vitus's dance. 



DISEASES OF THE NERVOUS SYSTEM. 403 

When heart-disease or a tendency to acute articular rheu- 
matism is the cause, preventives share largely in the success 
of the treatment. The hygiene must be strict and medicinal 
attention to the cardiac ailment close. The rheumatic child 
must be anxiously watched ; pain, be it ever so slight, re- 
quires rest in bed for one or two days at least and tentative 
doses of salicylate of sodium. Helminthes must be expelled. 

Neurotic children should not be overworked, the school 
sessions must be short. Cool or cold washes, with friction, and 
systematic, but simple and brief, gymnastics in the open air, 
not in a close school-room, will fortify them. The period of 
convalescence from any incidental disease must be passed in 
bed, which should be placed, if possible, near an open win- 
dow. Anaemia must be carefully watched and treated. The 
patient should not be allowed intercourse with neurotic, or 
choreic, or epileptic, or even merely violent children ; for 
some of the worst cases of chorea are those produced by 
fright. Headaches of a simply neuralgic or ocular origin 
must be attended to, the latter mostly by glasses, sometimes 
by the protracted use of strychnia, but not by misdirected 
and unauthorized operations when there is no disturbance of 
muscular accommodation. 

A patient sick with chorea minor must be kept quiet in 
body and mind. Bad cases will not get well, unless confined 
to bed in a quiet room, with no visitors or excitements, with 
but a single person present to entertain or read to them, with 
a warm, protracted bath daily, and with ample sleep. Very 
bad cases must be kept sleeping eighteen out of twenty-four 
hours by means of mild opiates or chloral hydrate with or 
without bromides. Sometimes large doses are necessary, but 
the effect must be obtained. I have met with cases in which 
an occasional inhalation of chloroform was also required. 
Meanwhile, the symptomatic measures adapted to the average 
case must also be attended to. 



404 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

The best symptomatic remedy is arsenic, in the form of 
liquor arsenitis potassii or sodii. Three doses are to be given 
daily, much diluted, after meals. When the eyes or the 
intestines begin to give trouble, or when a serious cutane- 
ous eruption makes its appearance, or should the urine show 
albumen and casts, it is time to intermit. The doses must be 
increased slowly but persistently, according to the rule de- 
tailed on page 96. The original dose can be doubled or quad- 
rupled ; indeed, can be increased almost indefinitely. The 
cause of failure on the part of arsenic is generally its insuffi- 
cient dose. 

Of other remedies, nitrate of silver may be mentioned ; it 
is of less service here than in some other ailments of the ner- 
vous system. Oxide of zinc or valerianate of zinc may be 
tried, if arsenic happen to be omitted. The galvanic current, 
warmly recommended by Benedict, has not satisfied me. Sul- 
phur bathing, either natural or artificial, is adapted to cases 
consequent on rheumatism ; it is indicated as after-treatment, 
as are also rational gymnastics and general roboration. 

Tetany has been observed in general disturbances of the 
general health, after gastro-intestinal disorders and during the 
presence of worms, in convalescence from acute and chronic 
(particularly infectious) diseases, after sudden exposures to 
changing temperatures, in chrouic malaria, after injuries to 
the head, as the result of irritation, or as a consequence of the 
abuse of alcohol. The fact of the occurrence of tetany after 
total extirpation of the thyroid gland may lead in future to 
a correct diagnosis of tetany in children and to an accurate 
examination of the thyroid gland. It is sometimes absent, 
or hypertrophied, or in an abnormal condition. The several 
causes enumerated above prove the occasional difficulty of a 
satisfactory etiological diagnosis, but suggest the preventive 
and curative treatment. Pilocarpine has been mentioned as 
the successful remedy in a case which was probably caused by 



DISEASES OF THE NERVOUS SYSTEM. 405 

exposure. Gastro-intestinal disturbances demand proper me- 
dicinal and hygienic treatment. Tetany after infectious dis- 
eases and during convalescence generally requires rest in bed, 
good air, copious (perhaps forcible) alimentation, and robo- 
rants. A very mild galvanic current, prolonged warm (not 
hot) bathing, bromides, chloral at night, and small doses "of 
codeine in older children will be required according to the 
severity of the cases ; they will get well after weeks or 
months. A roborant treatment with cod liver oil, iron, 
strychnia in small doses, phosphorus, and systematic exercise 
will restore the general health. The treatment with thyroid 
gland has not proved a great success in the average case. 

Exophthalmic goitre is not a frequent disease in childhood. 
Of twelve cases reported in literature until 1879, four were 
mine {New York Medical Record, July 5, 1879); they oc- 
curred in children of from nine to thirteen years. Nor are 
the symptoms so grave as they are liable to be in the 
adult ; in many, not all of the three alterations (exophthalmos, 
goitre, and tachycardia) are found at the same time. In the 
treatment proper regard must be paid to diet and hygiene. 
No excitement, fear, work, stimulants. Prolonged or but par- 
tial rest in bed at home or in a hospital. Baths of moderate 
temperature. Ice to the heart and (or) goitre for days, or 
hours, in succession. Application once or twice daily of a 
mild galvanic current (negative pole, from one to three mil- 
liamperes) from five to ten minutes over the sympathetic nerve, 
between the horn of the hyoid bone and the sterno-cleido- 
mastoid muscle. Digitalis acts badly, and is apt to increase 
the tachycardia ; strophanti} us and iodide of potassium act 
more favorably. Gowers recommends belladonna in rising 
doses. My most successful medicinal treatment has been with 
arsenous acid from two to six milligrammes, atropia from 
one-third of a milligramme to one milligramme, and extract 
of ergot a gramme daily. I have had no child's case under 



406 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

treatment since the partial extirpation of the thyroid body 
has been practised on adults. The internal administration 
of thyroid has proved a failure. 

Catalepsy is quite rare in children. I have seen but two 
well-marked cases, one of whom, a boy of thirteen, landed 
finally in a lunatic asylum. It is intimately related to hys- 
teria and epilepsy, and often attended by psychical disorders. 
Both its prognosis and its treatment are dependent on the causes, 
among which fright, masturbation, chlorosis, malaria, helmin- 
thiasis, epilepsy, and melancholia have been enumerated. 
Thus, depletion, diaphoretics, emetics, nervines, anthelmintics, 
and electricity have been recommended. In most cases medi- 
cines are less effective than is attention to general hygiene, both 
physical and mental. In this respect it shares the fate and 
prognosis of hysteria, of which it may be considered one of 
the manifestations the existence of which among children 
has been more extensively observed and studied since its 
presence, particularly in connection with masturbation, was 
discussed by me in 1875 {American Journal of Obstetrics and 
Diseases of Women and Children). Hirschel and Fleisch 
observed catalepsy after intermittent fever, and Glas noted 
the case of a boy of five years, who bad an attack of catalepsy 
(instead of a chill), followed by perspiration. In these cases 
quinia and arsenic take the place of other treatment, with 
better success. 

Another, though rare, symptom of hysteria is chorea magna, 
which differs from chorea minor in the occasional appearance of 
paroxysms of co-ordinate spasms with psychopathic prodromi 
and (frequently) termination. Altogether, hysteria occurs with 
all the symptoms met with in adults. It is not confined to 
the female sex in children any more than it is in adults, and 
exhibits the same debility and irritability of the nervous 
system in general and of emotions, reflexes, imaginations, and 
will in particular. It is found in psychopathic families as 



DISEASES OF THE NERVOUS SYSTEM. 407 

the result of mental strain, undue ambition, irritation, mas- 
turbation, diseases of the ovary, and emotions. Hysteria in a 
child means, unfortunately, in most cases, hysteria for life. 
Still, training and education are capable of accomplishing a 
great deal in strengthening will and character and indepen- 
dence of thought. Such children are better off among strangers 
than at home. School sessions ought to be regular but short ; 
work in the open air, housework, gymnastics, and hydro- 
therapy, with general roborants, are indicated and prove 
successful. 

Athetosis, that peculiar form of localized (ends of upper ex- 
tremities mostly) spasm, can hardly be improved when con- 
genital. Now and then it accompanies cerebral poliomyelitis 
or tumors. Improvement is claimed to have followed the use 
of arsenic, bromides, and galvanism. 

Most cases of epilepsy are observed in, or date from, infancy 
and childhood. In no disease is the hereditary influence more 
marked ; the state of the future will have to see to it that 
epileptic persons are not placed in a position to raise progeny 
equally cursed. Epileptic mothers must not nurse their 
babies. The child known to be epileptic must be trained 
very carefully, both physically and mentally. Alcohol and 
other stimulants, physical and mental exertions, and sudden 
emotions must be avoided. The hygiene of the skin and of 
the bowels requires particular care ; the use of cold water 
is imperative ; constipation must not be permitted. Feeding 
with gruesome nursery stories, tight dressing, and early school- 
ing, also horseback exercise and swimming, are forbidden. 
In the interest both of patient and of schoolmates a public 
school should not be attended. The child ought to be in- 
structed and trained with a view of preparing him for his 
future calling, which must not overstrain body or mind, must 
not be sedentary, nor should it confine him, if avoidable, to 
the limits and influences of city life and air. 



408 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

No case of epilepsy should remain without treatment. It 
is true that there are spontaneous recoveries ; even hereditary 
cases may get better or well ; remissions are frequent ; inter- 
vening acute diseases and many operations have frequently a 
favorable effect. On the other hand, Gerhardt saw a relapse 
after an intermission of twenty years. But the knowledge 
of these facts must not tempt us to procrastinate medicinal 
and hygienic interference, or to hold out a hope of recovery 
at the period of " second dentition," of " puberty," or of 
" marriage." 

The best methods of treatment are always either specific or 
local. Symptomatic treatment may prove very successful with 
the aid of all-healing nature, but it is always a makeshift. The 
ideal indications for the cure of epilepsy ought to be — nay, 
must be — causal ; its proximate seat is in the cerebral cortex, 
but its actual origin in anatomical lesions, mostly, of different 
localities. Thus, epilepsy may be cerebral, it may be the 
result of persistently abnormal circulation, or it may be of a 
reflex nature. All sorts of cerebral tumors, solid or cystic, 
the results of previous encephalitis and meningitis from inso- 
lation, otitis, or otherwise ; arrests of cerebral development ; 
premature ossification of one, more, or all of the cranial 
sutures and fontanels; cerebral exhaustion from masturbation 
or premature venery ; diseases of the heart with secondary 
venous obstruction ; congestion from other causes (in a case 
of Gerhardt's, enlargement of the thyroid) j the influence of 
prolonged use of alcohol or ergot; the sluggish brain circula- 
tion attending constipation and the general toxemia of 
intestinal autoinfection ; external irritations such as tumors, 
cicatrices, foreign bodies, and the reflex excitement produced 
by carious teeth, Schneiderian hypertrophy, and nasal and 
naso-pharyngeal growths ; vesical and renal calculi ; helrain- 
thes, from taenia to oxyuris ; in older children deferred 
menstruation, are so many different causes of epilepsy. It 






DISEASES OF THE NERVOUS SYSTEM. 409 

is, therefore, only the most painstaking examination of all 
the organs and the whole surface of the body which gives 
promise of finding the cause of the disease as well as the 
indications for rational causal treatment. 

Arrests of cerebral development are not amenable to treat- 
ment; the method of dealing with the chronic results of 
cerebral and meningeal inflammations, also the possible value 
of operations on prematurely ossified skulls, have been pre- 
viously discussed. Most of the operations on the cranium 
undertaken for the purpose of healing epilepsy have not been 
successful, and the most enthusiastic promoters of such opera- 
tions have rescinded their favorable opinions. Thus, the 
American Neurological Association, in a discussion which 
was mainly carried on by Sachs, Mills, Putnam, and P. C. 
Knapp, expressed itself very reservedly on this topic. But 
there is no doubt as to an occasional success, nor can there 
be any as to the feasibility of removing tumors from the 
surface and the cortex, or of opening and removing cysts and 
the results of new and old hsematomata. The human body 
not being a machine manufactured wholesale, and medicine 
not being mathematics, the indications both for medical and 
surgical interference are neither geometrically exact nor are 
they gospel. For these reasons mistakes are always liable to 
occur, and recoveries may not be obtained, though no error 
be committed ; for, indeed, habitual convulsions may be so 
firmly established that even the removal of their original 
source is no longer an efncieut cure. But the insufficiency 
of medicinal treatment may be such as to sometimes necessi- 
tate surgical interference as a last resort. 

It is particularly in cases produced by reflex from cica- 
trices and nasal irritation that local treatment, excision, cau- 
terization, and the removal of polypi and adenoid growths 
have their signal, though rare, triumphs. The eyes have been 
accused — " eye-strain" — of producing epilepsy, and hence 



410 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

have been submitted to operations. My remarks on that 
subject, as connected with chorea, I can but repeat here. As 
regards local treatment, we have also to consider the effect on 
the genital organs when they are the cause of epilepsy. There 
is no doubt as to the occasional efficacy of digitalis, lupulin, 
or camphor in such cases. In others a chemical effect is 
aimed at ; thus, in epilepsy from chronic lead-poisoning, 
sulphur baths, sulphur, and iodide of potassium internally 
have exhibited good results. 

If the approach of an attack be perceived, the patient 
ought to lie down on a low couch ; the inhalation of amyl 
nitrite, if in time, has warded off many seizures ; its effect 
must not go beyond the first deep flush. If an aura rises 
from an extremity, a stout ligature around the limb may also 
act as a preventive. When the seizure cannot be prevented, 
it must not be interfered with ; no hands must be forcibly 
opened, no convulsive jerking meddled with • but the patient 
must be protected against biting his tongue or otherwise 
hurting himself. Among the drugs recommended for epilepsy 
every narcotic and antispasmodic has had its day. Valerian, 
pseonia, and artemisia were once highly thought of; so was 
belladonna, and later atropia, with its paralyzing influence on 
blood-vessels. Curare was praised for its effect on the mus- 
cles. Sulphate of copper has been recommended. Nitrate of 
silver, in doses of not more than one or two centigrammes 
daily (gr. J-J), best in pills, may be continued, with intermis- 
sions, for a long time, and is credited with cures It ought 
not, however, to be administered more than a month in succes- 
sion, lest the skin show its effect. Twice in my life have I 
thus succeeded in producing argyria. Zinc has proved ser- 
viceable : the oxide, the valerianate (25 to 50 centigrammes 
daily), and the sulphate. The latter I have made much use 
of, beginning with three centigrammes (gr. J) three times daily 
for an adult (a child in proportion), in increasing doses. Four 



DISEASES OF THE NERVOUS SYSTEM. 411 

grammes (3i) are dissolved in one pint of water, the first dose 
being a teaspoonful for an adult, ten or twenty drops for a 
child, the second the same dose plus one drop, the third the 
same dose plus two drops, and so on until after twenty days the 
double dose, after forty days the treble dose is reached. It 
takes a long time for tolerance to become exhausted ; should 
this happen, a small reduction of the dose is all that is required. 

To reduce the irritability of the cortex and the general con- 
vulsibility, and thus in the course of time to cure epilepsy, 
the main reliance is on the bromides. I have not been able 
to convince myself of the injuriousness of the potassium salt. 
A belief in its harmful action has been the cause of the substi- 
tution of the sodium, or a mixture of the potassium, sodium, 
and ammonium salts. Whichever plan is followed, there are 
certain rules which are paramount. The remedy must be 
given for years ; it must not be interrupted unless there have 
been no seizures for years, except for very good reasons (ex- 
cessive acne, paresis, sopor, headache, and perhaps the in- 
tervention of acute diseases). The doses must be sufficient ; 
a child of two years may take three or four grammes (grs. 
45-60) daily. It is best to give a large dose at bedtime, 
perhaps half of the daily amount ; in this way the cerebral 
symptoms of overdosing are most readily avoided. When 
they appear the dose may be reduced, but, except in rare 
instances, the remedy should not be stopped altogether. 
Perhaps the strontium or lithium salt may take its place for 
a time, but I cannot say that either have impressed me with 
the superiority which has been claimed for them. The 
addition of moderate doses of digitalis has often appeared to 
me to reduce the drowsiness brought on by protracted large 
doses. Arsenic in small but regular doses will lessen the 
tendency to acne. 

I cannot say that bromides are badly tolerated in the 
evening; still, it is claimed that they have a disagreeable 



412 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

effect. In that case a sufficient dose of amylene hydrate to 
produce sleep should take their place. "Weber, of Dahldorf, 
precedes his bromide treatment by a regular course of amylene 
hydrate ; on the other hand, there are those who condemn its 
use altogether because of injurious effects which they claim to 
have observed (Jastrowitz, Jolly). 

Flechsig combines the bromide of sodium treatment with 
that of opium. His two or three daily doses of the latter, 
for adults, are from five to ten to twenty-five to thirty-five 
centigrammes each (gr. |— 6). After six weeks it is suddenly 
discontinued and replaced by 7.5 grammes daily (5ii) of the 
bromide. After this treatment has been continued two 
months the daily dose is reduced to two grammes. Flechsig 
claims no direct effect, but only a preparatory action on the 
disease. Indeed, during the opium treatment there was no 
relief; but in combination with bromide of sodium, cases 
which had lasted decades were improved. Radcliffe, however 
(according to Gowers, Lancet, 1880, p. 552), found opium 
effective in some cases. Gowers saw but rarely any good 
effects from bromides and opium combined, but believes in 
the usefulness of small subcutaneous doses of morphia when 
attacks reappear often and violently. The latest journal re- 
ports on the Flechsig treatment are very contradictory. 

Pasteur observed that in a patient under treatment for 
hydrophobia the epileptic attacks ceased (as they do cease after 
operations of any kind, strong emotions, or acute diseases). 
For this reason Charcot suggested systematic injections of 
rabic virus for the purpose of relieving or curing epilepsy. 
Gibier has imitated the process and claims good results. 
Pierre Marie goes so far — a good deal too far — as to believe 
that " idiopathic epilepsy," which he claims to be frequent, is 
of infectious origin in almost every case, is therefore prevent- 
able, and ought to be treated and cured with microbic toxin 
{Semaine Medicale, 1892, p. 283). 



DISEASES OF THE NERVOUS SYSTEM. 413 

The number of epileptics is so large, and the influence of 
the disease upon the intellectual, moral, and physical condition 
of the individual, as well as upon the state and mankind, so 
wide-spread, as to be alarming. The subject has finally roused 
the anxiety of philanthropists to a great extent. Country 
settlements of epileptics have been established in Europe, 
with beneficial results. As a result of combined efforts the 
following resolution was passed at a meeting of the American 
Neurological Association : 

" That it is the unanimous sense of the American Neuro- 
logical Association that the proper care of the epileptic class, 
so long delayed, be urged upon the public, upon State authori- 
ties, and especially upon all interested in the care of the sick 
and defective poor, whereby they may be retired from asylums 
and almshouses, and may receive the required care in such 
separate establishments as their deplorable situations demand." 

One of the results of this resolution was an act of the Leg- 
islature of the State of New York, by which a tract of land in 
the interior of the State was set aside for the purpose of estab- 
lishing colonies for epileptics. The world is moving. 

Salaam spasm (spasmus nutans), a peculiar affection of the 
accessory nerve, must receive the treatment proper for its 
causes, which are either central (rhachitical) or reflex (from 
intestinal disorders). Many of the patients are thoroughly 
anaemic. The indications are bromide of potassium, the posi- 
tive pole of the galvanic current upon the convulsive muscle 
(sterno-cleido-mastoid (or) and trapezius), also massage and 
antirhachitical treatment. 

Psychical diseases have been considered rare in infants and 
children. The statistics published by lunatic asylums and by 
specialists are meant to prove that. These statistics are cor- 
rect, but the conclusions drawn from them are not. Every 
practitioner knows better. Dementia and mania are by no 
means rare, melancholia and similar conditions of depression 



414 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

are not frequent. The public institutions do not contain such 
patients. A demented or even a maniacal child can be man- 
aged and prevented from doing harm to itself or to others, 
at home and by the family, better than an adult, and it is 
there that numerous such patients can be observed. The 
same forms of mental disease occurring in the adult are also 
seen in the young. Besides those which have been mentioned, 
we meet with moral insanity, monomania, epileptic and circu- 
lar dementia, even "paresis" and delirium tremens. More fre- 
quent than either or all of them are idiocy and cretinism, the 
former of which is a not rare final termination of mental 
anomaly in the adult, while in the young it is the first ap- 
pearance of aberration, though, indeed, but the result of 
ever so many different anatomical changes. Their varieties I 
have discussed above, also the possibilities of treating them 
medicinally or by surgical procedures (p. 380). Cretinism 
has some well-understood anatomical peculiarities or causes ; 
prominent among them are the shortening of the cranial base 
by premature ossification of the occipito-sphenoidal synchon- 
drosis and, it appears (principally), the absence or degenera- 
tion of the thyroid gland. Thus, the cretinism of the foetus 
and infant and the myxcedema of the adult are among the 
results of the same anomaly. 

In the therapeutics of cretinism in all its forms the thyroid 
gland, in its various preparations, has worked a beneficial 
revolution, as it also has in that of myxcedema in general. 
This addition to our facilities for overcoming a formerly 
incurable ailment, at least to a certain extent (for no perfect 
recovery is known as yet), is, as Meltzer has so well shown 
(New York Med. Monatsschrift, May, 1895), eminently due to 
biological experiment and to it only. There are but few cases 
that resist its efficacy. The doses, however, must be small, 
particularly in the beginning ; from one-third of a grain to 
one grain of Parke, Davis & Co.'s powdered thyroid three 






DISEASES OF THE NERVOUS SYSTEM. 415 

times a day, the small doses first, the larger one afterwards, are 
all that ought to be given an infant or child, according to age. 
The treatment must be continued a long time. It cannot be 
expected to act so well as in the myxoedema of the adult, because 
the cretinism or semi-cretinism of the child is the result of an 
arrest of development at a very early period of intra-uterine 
life. It follows that the treatment ought to begin as early as 
the diagnosis can be made. Besides the powder of Parke, 
Davis & Co., I know only that of Armour and the tablets 
of Burroughs and Wellcome. They are not of equal strength, 
and in every case ought to be commenced with in small doses ; 
for sometimes even apparently small doses produce general and 
cardiac irritation, palpitations, tremor, debility, and diarrhoea. 
Other effects of the thyroid medication are obtainable in the 
child as in the adult. Myxoedema, the near relative of cretin- 
ism, shows its main symptoms in the subcutaneous tissue, in 
the skin, and in the nervous system. I have seen good results 
of the thyroid treatment in cases of excessive adiposity, — one 
boy of eleven years, weighing one hundred and fifty pounds, 
was reduced to one hundred and twenty in four months under 
the use of small doses, — in scleroderma, and in a case of 
psoriasis. Fortunately, all such cases are rare. 

My object in enumerating most of the possible causes of 
mental disorders in the young is principally to show that 
preventive treatment must be considered more reliable than 
curative. Heredity plays an important role, so does inebriety 
and all other forms of psychical aberration or serious nervous 
disorders, — epilepsy, diabetes. To what extent matrimony be- 
tween relatives contributes to mental disease in the offspring 
is by no means proved. I cannot, from theoretical reasoning 
and from practical experience, admit that two healthy per- 
sons, be they ever so nearly related, will for that reason have 
a diseased child. But to what extent the state of the future 
will interfere with the marriages of insane and epileptic peo- 



416 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

pie, as also with those of carcinomatous or tuberculous patients, 
provided our therapeutics continues as unsatisfactory as hith- 
erto, remains to be seen. It is but natural that the rapid 
favorable changes of the last few years in our therapeutics, 
both internal and external, should increase our hopes in re- 
gard to great results. 

Diseases of the foetus, mostly of inflammatory character, 
— meningitis, encephalitis, — predispose to mental symptoms. 
During birth, a prolonged labor or undue pressure by pelvis 
or forceps invites hemorrhage with its results. Spontaneous 
hemorrhages are the more common and the more dangerous 
the younger the infant. Congestions and inflammation of the 
meninges or of the brain are frequent in the infant and child. 
Their causes are rhachitis of the cranium, insolation, hot 
stoves and bed-pillows, tumors, stimulants, such as coffee, tea, 
and alcohol, falls and blows, and diseases of the heart. Dis- 
orders of the ears are frequent, and affections of the nose not 
unheard of causes of intra-cranial disease. Infectious diseases, 
such as typhoid, scarlatina, erysipelas, rheumatism, influenza, 
are known to be direct causes of mental disturbance in the 
young. The removal of intestinal worms has ended a psychi- 
cal disorder. I have known overexertion at school to result 
in mental aberration, which terminated either in recovery or 
in death from exhaustion or meningitis. The period of 
puberty, with its sudden changes, creates a predisposition, and 
excessive masturbation may cause derangement. Bad habits, 
bad training, and congenital migraine add oil to the fire. 

This cursory enumeration of causes gives plenty of food for 
thought. The conscientious family physician with a number 
of infants and children under his charge has a great responsi- 
bility. His cares ought to begin with conception. Many a 
case of infant meningitis (hydrocephalus) can be prevented 
by timely attention to the mother. Labor must not be per- 
mitted to last too long, asphyxia in the newly-born must be 



DISEASES OF THE NERVOUS SYSTEM. 417 

immediately attended to, and strict care should be taken of 
the diet and hygiene of the baby. Errors in this respect are 
not punished immediately ; and while some babies thrive, or 
appear to thrive, while these are being constantly committed, 
in others the foundations are being slowly laid for ill health 
and serious disease, both physical and mental. That heart 
and ears ought to be attended to in time, and persistently, is 
self-understood ; but procrastination — waiting for better times 
and "second dentition" and "puberty" — is too common an 
occurrence. Perhaps the greatest negligence on the part of 
medical men is exhibited in regard to mental overwork. 
Our schools have become hot-houses in which scoliosis, near- 
sightedness, anaemia, neurasthenia, chlorosis, and cerebral ex- 
haustion and disease are being bred in incredible numbers. 
Even the apparent offset to this mental overwork — gymnastic 
or " calisthenic" exercise in the same building, as part of the 
curriculum — adds to the general exhaustion. It is time that 
the medical profession looked into the increasing degeneration 
of the people resulting from this overstraining of the young 
brain, ninety per cent, of the growth of which is not attained 
until the seventh year, and the full growth not reached before 
the fourteenth or seventeenth. Physicians will do well to be 
no longer afraid of the charge of going into politics. If they 
do not wish to be " politicians," let them be something better, 
and turn statesmen. 

The general remarks made on the first pages of this chapter 
will suffice for both the general and causal treatment. Serious 
and unmanageable cases belong to an institution. Conditions 
of excitement, besides proper hygienic and dietetic treatment, 
require rest in bed, warm bathing (not hot), and plenty of 
sleep, which latter may be procured by opiates (extractum 
opii, codeia), or hyoscin, or chloral. 

Mild forms of temporary mental aberration are the night 
terrors (pavor nodurnus). They are mostly (not always) met 

27 



418 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

with in delicate, pale, scrofulous, or rhachitical children, with 
neuropathic tendencies somewhere in the family. Like 
attacks of genuine dementia or mania, they are not remem- 
bered by the patients. But few of them are attended by 
fever ; many result from or are connected with digestive dis- 
orders. Heavy meals, particularly in the evening, must be 
avoided, also emotions, frights, ghost-stories, exciting games ; 
the bowels should be kept relaxed. A dose of quinia bromide 
or potassium bromide at bedtime and a room not absolutely 
dark are good preventives. 

Stammering is pre-eminently a disease of the nervous system, 
and is probably caused by a diseased condition or insufficient 
tone of the cerebral cortex, with lack of equilibrium, exhibited 
in some by choleric temperament, in others by cowardice, 
together with disturbance of will power and an absence of 
co-ordination of respiration and the muscles of the larynx 
and mouth. In some it is the result of nervous talkativeness, 
fidgetiness, and flightiness on the part of parents or attend- 
ants; in some of imitation not checked at the proper time. 
Strengthening of mind and body is the main indication. 
Training, cold water, and exercise will fortify the character ; 
bromides may for a time relieve irritability. Co-ordination 
of innervation and muscle may be achieved by loud and slow 
speaking and by reading, reciting, and singing. Self-confi- 
dence must be encouraged in every way. Among strangers 
and in institutions established for the purpose such patients 
are most benefited, not infrequently in a short time. Local 
affections of the respiratory tract must be attended to, adenoid 
vegetations of the naso-pharynx removed, and other anomalies 
of the nares corrected, provided they interfere with respiration. 



DISEASES OF THE SKIN. 419 

XI. 

DISEASES OF THE SKIN. 

Burns. — Burns of the first degree rarely require more than 
cooling applications and rest, both general and local, water, 
lead wash of different strengths, oil, and cotton. Persistent 
cold applications are not tolerated. When large blisters have 
been formed, the epidermis should be removed and an appli- 
cation made of equal parts of lime-water and oleum lini, to 
which a twentieth of a per cent, of thymol may be added. 
The burn should then be thickly covered with aseptic gauze. 
After this application is removed, a fine powder of bismuth 
nitrate should be spread over the wound and the whole covered 
with gauze again, or an ointment containing bismuth, or bis- 
muth and boracic acid, or bismuth and zinc may be employed. 
To thoroughly guard against infection, the washing of the 
wound with a three-per-cent. solution of carbolic acid, or of 
salicylic acid, or of boracic acid (not so painful as the other 
two) must precede the application of a gauze thoroughly 
covered with bismuth nitrate finely powdered, or with a mixt- 
ure of bismuth and starch, or the same with the addition of 
from one to two per cent, of salicylic acid. Such an applica- 
tion may remain undisturbed for weeks. Extensive burns do 
well in the permanent warm bath. Should large defects result, 
transplantation may be practised afterwards ; if contractures, 
extension must be employed in time and apparatuses used for 
a sufficient period. 

The younger the patients the more liable are they to suffer 
from burns, though apparently mild. Much reaction may set 
in after a day, with high fever and convulsions. Therefore 
the thermometer ought to be consulted soon after the accident 
and the symptoms prevented or treated. Diarrhoea is not un- 



420 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

common, even after moderate burns, and requires opium and 
the regulation of diet ; collapse demands stimulants, either in- 
ternal or subcutaneous ; and sleeplessness appropriate narcotics. 

Burns are more frequent than are the effects of cold. Com- 
mon frost-bites are frequent, it is true, and annoying, but rarely 
of great importance. The rubbing of red, itching, and swollen 
parts with snow (or with petroleum) is quite effective in mild 
cases. The itching is often relieved by a mild tincture of 
iodine or by the application of a (from three to ten per cent.) 
solution of nitrate of silver or of chloride of calcium in water 
(1-2 : 100). The popular remedies of tallow and whiskey or, 
better still, the application of carpenter's glue to frost-bites 
yield relief. This may also be obtained by surrounding the 
inflamed swelling by a protecting (corn) plaster. Vesicles on 
the toes and heels, filled with blood and resulting in ulcera- 
tions, require the latter treatment, together with subnitrate of 
bismuth, or naphtalin, or cauterization with nitrate of silver 
until granulations spring up, or an ointment of balsam of 
Peru with or without zinc oxide, or bismuth. Gangrene of 
the skin or of whole extremities is, fortunately, rare. When 
it occurs it demands rational surgical treatment. 

Erythema is met with at every age of infancy and child- 
hood, and depends on a number of causes. The treatment is, 
therefore, partly symptomatic, partly causal. In the newly- 
born, from the establishment of an unprecedented cutaneous 
circulation and the discontinuation of the intra-uterine am- 
niotic pressure, the skin becomes red, changes into yellow 
(alterations of hsematin), is subject to extensive peeling, and 
obtains its normal pink color under ordinary circumstances. 
The erythema, however, is not always uniform ; now and then 
it bears a resemblance to measles, and is attended by fever, 
but not by catarrh. As a rule, it demands no treatment, 
except preventive. The bath must not be hot, the temperature 
of the room not abnormally high, the bedding not hot and 






DISEASES OF THE SKIN. 421 

oppressive. Vaseline, cold cream, or lanolin is useful where 
the redness and the tendency to peeling are very marked. 

In the following months erythema is a common symptom 
when the babies are exposed to pressure or friction by clothing, 
to heat of summer, stoves, bedding, or bathing, to irritation 
by urine, or to the septicemic after-effects of infectious fevers, 
such as measles, angina, diphtheria, typhoid, or influenza. In 
some of these cases desquamation is observed ; it is the more 
readily a cause of mistaken diagnosis the longer it lasts and 
the greater its extent proves to be. Children of three or four 
years, when afflicted with diarrhoea and consecutive cachexia, 
are subject to a papular erythema which is mostly confined to 
the gluteal regions and the extremities. Finally, thin and 
feeble children frequently exhibit a general redness, sometimes 
mottled, which lasts as long as does the sluggish circulation 
depending on their general condition. 

The indications for treatment in all of these varieties are 
furnished by the causes. Irritation of the surface must be 
avoided ; the patient must not be exposed to abnormal temper- 
atures, either of air or water, or to errors in diet ; diarrhoea 
and emaciation must be arrested, and vaseline and fats used 
according to necessities. In many cases a full supply of 
drinking-water, which is too frequently withheld from the 
very young, corrects the evil by stimulating cutaneous circu- 
lation and the tendency to perspiration, which is almost absent 
during the first month and very scanty in the second and 
third. 

Constipated and dyspeptic children are very apt to suffer 
from erythema as the result of intestinal autoinfection, some- 
times to such an extent that the diagnosis between it and scar- 
latina may become doubtful. The difficulty grows in those 
cases in which the intestinal erythema is attended by the corre- 
sponding intestinal fever, an occurrence not at all uncommon. 
Constipation may be congenital or acquired, and may lead to 



422 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

the same result. The diagnosis is not always easy for other 
reasons, — viz., the apparent normality of the stomach, the 
absence of diarrhoea, and the actual or alleged absence of flat- 
ulency. This erythema is not uncommon ; it may last hours 
or many days, or may alternate with acute attacks of urtica- 
ria. The latter is, therefore, not always gastric or neurotic, 
either in its acute or chronic form, and it thus shares the 
etiology of many cases of acne and some of senile pruritus. 
When occurring in the face exclusively, I have seen it mis- 
taken for erysipelas. 

This variety of erythema is sometimes seen mostly on the 
hands and feet, is symmetrical, and now and then, like urticaria, 
has vesicles or bullse (similarly to herpes iris). When of intes- 
tinal autoinfection, it is usually accompanied by indican and 
the ether-sulphuric acids in the urine, which is liable to be 
very scanty and of high specific gravity. Skatol and indol 
are found in the faeces. In most cases a purgative (prefer- 
ably calomel) will bring speedy relief, but actual and lasting 
aid will only come from prolonged disinfection of the intes- 
tinal tract by naphtalin, salol, resorcin, oil of peppermint, 
small doses of calomel or bichloride of hydrargyrum, by 
large enemata containing a twentieth of one per cent, of 
thymol, or such as consist of aromatic infusions (mint, catnip, 
chamomile) exclusively, occasional purgatives, and by the regu- 
lation of the diet, which must be such as not to cause fermen- 
tation and putrefaction. In the employment of the sulphites 
(of sodium and magnesia) I have been rather disappointed. 
The use of menthol is not to be recommended ; it can be 
swallowed in capsules only, and to atone for its local irrita- 
tion it has no eminent virtues. 

Erythema nodosum may be discussed in connection with this 
subject. It consists of large nodes, whose redness turns yel- 
low in the course of the normal alterations of hsematin ; it is 
mostly seen on the legs, but also along a number of tendons 



DISEASES OF THE SKIN. 423 

from the occiput downward. It requires rest. When it is the 
result of rheumatism, salicylate of sodium is indicated ; when 
it depends on malaria (Moncorvo), quinine. A six-per-cent. 
solution of nitrate of silver has been recommended for ex- 
ternal application. I have used with benefit, I believe, inunc- 
tions of oleum gaultheriae, of iodide of potassium in glycerin 
(1 : 2-4), and of iodide of potassium and lanolin ointments. 

Erythema complicated with loss of epidermis, either spon- 
taneously or through irritation by urine or faeces, or by friction 
of the adjoining surfaces of the nates, thighs, axillae, and the 
folds of the neck, together with secretion, and even crusts, is 
called intertrigo. It is mainly noticed in fat, flabby, and 
rhachitical babies, is painful and annoying, and may prove 
dangerous by becoming gangrenous or by inviting the invasion 
of erysipelas or diphtheria. Therefore, its treatment and cure 
are imperative. The diapers must be soft, not pinned during 
sleep, and frequently changed ; the babies must be kept scru- 
pulously clean and bathed at least once a day. A seven-per- 
mille solution of table- salt is more pleasant than water alone. 
Diarrhoea must be relieved by dieting, internal medication, 
and rectal injections. Astringent solutions (sulphate of zinc, 
tannin) would be beneficial but for the difficulty of making 
regular applications; ointments containing zinc oxide, bis- 
muth, tannin, or lead are preferable. Fine powders of bis- 
muth subnitrate, of talcum, of amylum, or mixtures of two 
of them, with or without the addition of one or two per cent, 
of salicylic acid, will act satisfactorily. The popular ly co- 
podium powder is not to be recommended. By reason of its 
gluing together it forms foreign bodies which prove irritant. 

In addition to what has been said on the treatment of ery- 
sipelas (pp. 177, 178), I ought to mention ointments of ich- 
thyol, which have been recommended ; but I cannot say that 
my results have been encouraging. The compound tincture of 
benzoes may be used all over the inflamed surface once every 



424 THERAPEUTICS OP INFANCY AND CHILDHOOD. 

hour or two hours. Absolute alcohol (99°), applied constantly, 
appears to render good service in limiting the area of infec- 
tion. That is what is aimed at and accomplished (where the 
locality permits) by the hedging in of the morbid process. Rail- 
fence-like scarifications iuto the rete Malpighii, double, crossing 
each other, are made to enclose the erysipelas, and corrosive 
sublimate (1 : 500) is rubbed into the wounds under anaesthe- 
sia, in most cases with almost instantaneous, at all events rapid, 
success. To modify this procedure, as is done in one of the 
large children's hospitals in Germany, by incising the surface 
of the erysipelas and squeezing it so as to empty the oedema, 
then scarifying deeply round it and rubbing in ichthyol, and 
repeating the process until scurfs are formed, appears to come 
dangerously near the permits and privileges of criminal law. 

Among the circumscribed inflammations of the skin met 
with in children, mostly of advanced age, are acne, lichen, and 
prurigo. Acne is dependent on an interrupted action of the 
sebaceous follicles. They begin their rapid development about 
the middle of intra-uterine life, and are large and numerous at 
birth, particularly over the nose, ear, eyebrows, and around 
the mouth. When obstructed, they exhibit in the infant no 
black-heads like the comedones of the adolescent or adult, but 
are white. Normally, they secrete much tallow, which gives 
the foreheads of many babies their shining, glossy appearance. 
When this tallow accumulates and gets dry, and mixes with 
the scabs of the epidermis and foreign material, such as dust, 
etc., it forms seborrhoea of any shade of color between whitish 
and black, which is more difficult to remove because of the 
conservative superstition of the mother than because of its 
own obstinacy. Its importance and its dangers are quite 
local ; it interferes with the growth of hair and predisposes 
to local irritation of the scalp; it ought to be removed by 
oil, fat, soap, hot water, and brush, and the subjacent hypera> 
mia relieved by an astringent ointment. 



DISEASES OP THE SKIN. 425 

When acne has formed (in older children) the comedones 
ought to be squeezed out. For this purpose an old-fashioned 
watch-key with broad edges will prove as serviceable as the 
mechanical devices of instrument-makers. Frequent hot wash- 
ing with green soap, or spirits of soap, followed by ice-cold 
washing, I have found very successful ; besides, the skin should 
be washed four times a day with a solution of corrosive sub- 
limate in water, or in alcohol and water (1 : 20-2000 or 
1 : 20-1000). 

Washiug with vinegar dissolves the epidermis cells and 
thus aids in disintegrating and loosening (lie obnoxious mate- 
rial. Hebra recommends his paste. Various mixtures of 
emplastrum and unguentum plumbi may be employed. After 
a thorough cleansing with soap, equal parts of lac sulphuris, 
glycerin, and alcohol (to bo preserved in a well-stoppered jar) 
are applied in (lie evening and washed oil' in the morning; or 
beta-naphtol 10 parts, precipitated sulphur 50 parts, lanolin 
or vaseline 25 pails, and green soap 25 parts are applied, and 
removed by washing after fifteen or twenty minutes, after 
which the skin is covered with talcum or starch. Only in 
I he very worst forms of acne (fortunately, rare in children) 
must scarifications be resorted to. 

Lichen is mostly found in its mildest form : strophulus of 
pin head size, slightly excavated on top, round a hair. It is 
not particularly resistant, but is liable to return. Lichen 
scrofulosorum, however, is apt to be obstinate. It is mostly 
met with in older children, is of a yellowish or red color, and 
forms a circle round a hair. It does not itch very muoh, 
but by reason of its duration and looks is quite annoying. 
I vocally, warm bathing and frequent ablutions with vinegar 
and water (1 : 3-6) will act well. Antipyrin in a nightly dose 
will relieve itching whenever troublesome, and by its sudorific 
effect will contribute to the disintegration of epidermic accu- 
mulations. The general treatment of scrofula is required for 



426 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

its causal indication. Lichen acuminatus and planus consist of 
circular nodules congregated round a pigmented spot, the first 
in rows, the second flat. Both are rare in children. 

Prurigo is found, of pin-head size and pink color, on the 
extensor side of extremities and in the gluteal region and ab- 
domen. In its neighborhood the lymph bodies swell, and 
chronic pigmentations are frequent. The itching is terrible, 
intolerable, exhausting, and may prove fatal. Twice I saw it 
complicated with or depending on diabetes ; in both cases it 
terminated with the fatal cause. Inunctions of glycerin or fat 
and protracted warm bathing in water or alkaline water should 
be resorted to. The baths ought to be continued for hours, 
and may be allowed to last half a day. Vinegar will dissolve 
the epidermis. Pilocarpine will do well in subcutaneous in- 
jections large enough to produce perspiration. As much and 
as long as permissible it may be combined with antipyrin ; 
and if subcutaneous injections be found impossible, it ought 
to be administered internally. Tar, sulphur, and green soap 
have been found very useful, when continued for from four to 
six weeks in alternation with warm baths. Wilkinson's oint- 
ment contains all of them (flor. sulphuris, ol. rusci, aa 10 
parts ; sapon. virid., vaselin., aa 20 parts). Kaposi recom- 
mends naphtol ointment (5 : 100). But it must not be forgot- 
ten that the prognosis becomes more serious with every month 
or year of the duration of prurigo, and that general and pre- 
ventive treatment demand urgent consideration. Most patients 
are stricken in their second year ; thus a hereditary influence 
is to be suspected in many. Often the parents are tubercular. 

Furunculosis in the very young does not often exhibit the 
same character as in adults. Both the sebaceous follicles and 
the perspiratory glands being rather patent, there are rarely 
such large and hard indurations. It is often complicated 
with acne, or follows eczema, and may complicate scabies. 
It is frequently found in cachectic infants and children and 



DISEASES OF THE SKIN. 427 

after protracted diarrhoea, generally in the form of multi- 
ple and cold abscesses ; sometimes in connection with tuber- 
culosis. These abscesses are liable to lead to extensive sup- 
purations of the connective tissue. The skin must be kept 
disinfected either by blue ointment or by corrosive sublimate 
in water (1 : 2000-5000). Abscesses — no matter how many 
— must be incised and disinfected with sublimate solution, 
or iodoform, or treated with the sharp spoon, or filled with 
antiseptic gauze, according to circumstances. Now and then 
these abscesses are found near the matrix of the nails, not 
multiple as in syphilis, but localized, and are liable to destroy 
the matrix unless incised aud disinfected in time. Secondary 
lymphatic swellings round the neck will, when benign, dis- 
appear after a while. If not, they are probably tubercular, 
and if persistent, without a tendency to get smaller, ought to 
be enucleated. A preventive measure is the covering up of 
incipient furuncles with some indifferent plaster (saponis, bel- 
ladonna ; no turpentine) to avoid the friction of the clothing. 
Arsenic in small doses, but persistently given, has a favorable 
effect. 

One of the most common forms of dermatitis in the young 
is eczema in its different forms, from the small vesicular and 
papular, with but slight desquamation or the formation of thin 
scabs, to the purulent variety (impetigo), with moderate crusts, 
and the rapidly growing and pointed ecthyma and rupia. 
For, indeed, all of them are but varieties of the same process. 
It may be microbic in isolated cases, but certainly is not a 
microbic disease generally. It may be complicated, however, 
with a parasitic ailment such as scabies. A disposition is 
generated by the tendency to congestive, catarrhal, or inflam- 
matory disease such as is understood by " scrofula," not by 
tuberculosis ; also by rhachitis, chronic indigestion, and anae- 
mia ; also by incidental fevers, — for instance, that of vaccinia ; 
indeed, it is not uncommon to date the first appearance of 



428 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

eczema back to the effect of vaccination. These occasional or 
constitutional partial causes of eczema must be considered 
as regards general and constitutional treatment. These are 
the cases apt to be benefited first by appropriate diet, then by 
the protracted use of arsenic, the hypophosphites, cod-liver 
oil, and iron. Still, it is important never to be tempted to 
begin such a treatment in an acute attack of eczema, which is 
more apt to be benefited by a few moderate doses of quinine 
and purgatives. 

Acute eczema is liable to run its course with a great deal 
of swelling and irritation, in these respects resembling ery- 
sipelas. It bears absolutely no water, and no ointments in 
the beginning. Powders of amylum, or subnitrate of bis- 
muth, or oxide of zinc, pure or in different proportions, with 
or without the addition of one or three per cent, of salicylic 
acid, prove more efficient. After a while the same constituents 
may be used as ointments. 

Most of the cases presented for treatment are chronic, 
either in the moist, or crusty, or squamous form. Many of 
them are itching, and are apt to lead to persistent infiltration 
of the skin, even amounting to elephantiasis. In many of them 
the original local causes are still persistent and can and must 
be relieved or removed. All sorts of local irritation are found. 
Seborrhcea, uncleanliness, secretions of nose, ear, and eye which 
are permitted to remain and irritate the neighborhood, the 
oral secretion of dentition excoriating the cheeks and chin, 
the septic piercing of the ear, the presence of vermin on the 
skin, are all frequent causes of eczema, the predisposition to 
which is established on certain parts of the body where 
eczema is most common (head and face) through the large 
size of the carotids and the physiological congestion and rapid 
development of the head and all its organs. By mistaking 
this connection, even the protrusion of the teeth has been 
charged with producing eczema. Indeed, everything causing 






DISEASES OF THE SKIN. 429 

sluggish circulation and congestion to the surface — the con- 
stipation, for instance, of fat babies, hot bathing, the influence 
of solar and stove heat — may have the same result. 

The effect of protracted eczema on the head is liable to 
be grave by its interfering with the growth of the hair ; by 
causing and extending catarrh of the ear and nose, or blepha- 
ritis, conjunctivitis, or keratitis ; by producing open sores and 
thus facilitating the invasion of erysipelas and (probably more 
frequently) tubercle germs ; by irritating and tumefying the 
numerous lymph bodies of the neighborhood with the com- 
plication of hyperplasia or tuberculosis. Thus, the indications 
for treatment are urgent in every case of eczema ; the sooner 
it is suppressed the less is the number of complicating dangers 
which are direct outgrowths of what appears to be, in most 
cases, a merely local affection. 

The necessity for local as well as general hygienic and 
constitutional — mostly preventive — treatment is pre-eminent. 
The body of the infant must be kept clean, but the local 
eczema should not be touched by water more than is absolutely 
necessary ; the reaction after a bath is liable to bring out a 
new crop. If the eruption be on the head, the hair must be 
cropped close. The nails must be kept short so as to a certain 
degree to prevent scratching. Remove thin or thick scabs by 
warm water, soap and water, warm fomentations (not on the 
head), oil, fat, liquor potassii in oil or cod-liver oil (1 : 8-12). 
Use the comb when the scabs are beginning to loosen. Be- 
low them the surface is hypersemic or oozing ; therefore the 
secretion must be dipped up and stopped as soon as possi- 
ble. Solutions of astringents are neither so convenient nor so 
effective as ointments. The official zinc ointment will suffice 
in many cases. Vaseline by itself is irritating. Bismuth sub- 
nitrate 5 parts, with ungt. zinci and vaselin., aa 20 parts, is a 
good combination. Such applications may be made from two 
to five times a day. Hebra's ointment is thickly spread on linen 



430 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

and the surface covered with it ; layers of it may be worn for 
days or weeks. There is no harm in the extensive use of 
lead ; I never saw or heard of a case of direct cutaneous ab- 
sorption which stood criticism, but I have seen lead-poisoning 
in a child who scraped the lead ointment from his cheeks and 
ate it for many weeks in succession. The formulae now and 
then published in the journals are very numerous ; every 
thoughtful practitioner will make or combine his own from 
bismuth, zinc, lead, and tannin. In addition to these, I men- 
tion for inveterate cases and the scaly form tar (tar, alcohol, 
and green soap in equal quantities, or ol. cadinum 1 part, ol. 
oliv. 1 part, lanolin. 10 parts) and hydrargyrum ammoniatum 
(either the official ointment or a modified formula, such as 
zinc oxide 1 part, hydrate of ammonia 1 part, ol. amygdal. 
dulc. 1 part, fat 10 parts), and, finally, nitrate of silver. It is 
mainly in chronic cases of eczema — the crustaceous or squa- 
mous variety — that a large surface will heal under the influ- 
ence of a solution of from three to ten per cent. 

Tar has but one grave inconvenience. On skins which 
absorb rapidly it may prove dangerous to the kidneys. 
Nausea, vomiting, diarrhoea, headaches, vertigo, and a smoky 
or even black urine, occasionally with more than mere albu- 
minuria, may be observed. The same, to a greater degree, 
must be said of carbolic acid, which may be added to oint- 
ments (2-3 : 100) to relieve itching. It requires watching. 
Where it cannot be used, cocaine (2-5 : 100), ointment of lead, 
zinc, or bismuth may take its place. Where the surface 
healing is slow, the proliferation of tissue can be accelerated 
by balsam of Peru (1 : 10) ointment. 

Pemphigus is more frequently observed in the newly-born 
and very young than in older children, mostly on the face 
and trunk, with a pale or hyperaemic basis, running its course, 
inclusive of the drying of scabs, in from six to twelve days, 
seldom chronic, and mostly so mild that no scabs remain, 



DISEASES OF THE SKIN. 431 

except when it is complicated with diphtheria or general 
cachexia. The serum (albuminous and mostly neutral or 
alkaline) contained in the bullae becomes turbid after some 
days, but seldom sanguineous. There is rarely any fever. 
New crops may start up. Strelitz and Almquist gave them- 
selves pemphigus through cocci. Riehl found in a single 
case a fungus resembling very much the trichophyton tonsu- 
rans. It is mostly found in institutions, and will spread to 
nurses or to members of the same family ; it seems, therefore, 
to be contagious, and is disseminated through careless mid- 
wives. Isolated cases are the result of hot bathing and bed- 
ding. The treatment is suggested by the causes thus far 
enumerated. Beware of heat and of contagion. Cleanliness 
and disinfection are required as preventive and curative meas- 
ures. Astringent ointments or bismuth powders are demanded 
locally, particularly where the epidermis has been torn off; 
general roborant treatment is required for puny and cachectic 
children, and antipyretics if (in exceptional cases) the tempera- 
ture rises to an unbearable degree; for even delirium has 
been observed. In most cases powders of bismuth, talcum, 
amylum, zinc oxide, etc., render good service. 

Pemphigus foliaceus, where no scabs form, but relapses take 
place contiguous to the first starting-point, is serious and apt 
to terminate fatally. Pemphigus exfoliativus, which, according 
to Hitter, begins at the mouth and extends all over the body, 
with an angry redness, gangrene, and phlegmons, and is fatal 
in one-half of the cases, requires careful and roborant nutri- 
tion, astringent ointments and baths, and stimulation. 

Neuropathic affections of the skin are apt to be congenital ; 
while not always connected with cerebral defects resulting in 
paralysis or epilepsy, like the papillomata described by Neu- 
mann (fissured warts following the course of a nerve and cov- 
ering the whole side of a body), still, they are serious enough, 
and sometimes not amenable to treatment. The congenital 



432 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

disposition to the formation of vesicles is in later life often 
combined with other neuropathic symptoms. The pemphigus 
neuroticus chronicus described by me (" Transactions of the 
Association of American Physicians," 1894) is of that nature. 
To this class also belongs urticaria pigmentosa, which yields 
ever-returning crops, many of them with consecutive and per- 
sistent pigmentation. Even common warts are probably, in 
many instances, trophic disorders of a neurotic character ; 
their sudden appearance in great numbers and their some- 
times unexpected disappearance seem to prove it. While 
fuming nitric acid is a fair local application, the internal use 
of arsenic is often of much advantage. This is certainly the 
case in what has been noticed first by Hebra as " verrucse 
planse juveniles," and carefully described by Thin. These 
warts are met with in children and adolescents on the face 
and back of the hands and fingers ; they are yellowish or red- 
dish brown, of the size of a pea or less, flat with a central 
depression, and may have frequently been mistaken for lichen 
ruber planus. 

A neuropathic oedema has been described by Widowitz ; it 
makes itself known, after exposure to cold, by extensive 
tumefaction with livid edges, and without any complication 
on the part of heart or kidneys. A neurotic cyanosis has been 
reported by Tordeus, and by him connected with dentition. 

Symmetrical cutaneous hemorrhage connected with cerebral 
disorder has been reported by Epstein ; erythromelalgia in a 
child, by Baginsky ; symmetrical cutaneous gangrene (Eay- 
mond) of feet, nose, and ears, with hemoglobinuria, in a boy 
of three years, by Abercrombie ; in children of seven, eleven, 
and thirteen years, belonging to the same family, by Braman. 

Scabies is apt to become chronic in children because it is 
often mistaken for or complicated with the various forms 
of eczema and " prickly heat." A mistake is also facilitated 
because it is not pre-eminently the fingers which are affected, 









DISEASES OF THE SKIN. 433 

but also the face, the gluteal region, the abdomen, and the 
joints. These constitute a difference from prurigo, in which 
the extensor sides of the extremities are principally affected. 
The skin must be thoroughly cleansed with soap every morn- 
ing, after balsam of Peru, or balsam of Peru 15 parts, alco- 
hol 10 parts, or balsam of Peru and vaseline, in equal parts, 
have been copiously applied the evening before. A few such 
applications will suffice, but they stain the linen. The un- 
guentum sulphuris of the Pharmacopoeia is too irritating to 
the skin of children, but may be mitigated by the addition 
of fat, sty rax liquid us, and olive oil, in equal parts ; creolin 
(5-10 parts in 100 parts of olive oil) or naphtol with fat 
(5-15 : 100) will also render good service. The clothing must 
be thoroughly washed in hot soap and water or disinfected 
with sulphur. Both naphtol and styrax may irritate the kid- 
neys, so that both are contraindicated in children with renal 
affections. In them, Williamson's ointment (ol. rusci, flor. 
sulph., aa 20 parts ; sapon. virid., vaselin., aa 40 parts ; cret. 
alb., 10 parts) is advisable. 

Impetigo contagiosa has thinner vesicles than pemphigus 
and no fever or inflammatory basis. It is found on the un- 
covered parts of the body, face, hands, and feet; the vesi- 
cles are small or large and spread rapidly, and relapses take 
place. Serious results have not been noticed ; still, a case of 
nephritis is reported as a sequela in a girl of twelve years. 
It is met with in schools and after wholesale vaccinations, 
through infection by vaccine lymph. Lassar found the 
staphylococcus aureus. As many as a thousand cases have 
been observed in a single epidemic. The treatment must be 
preventive, if opportunity be given ; a school in which the 
disease is found ought to be closed temporarily and disinfected. 
The local (and general) treatment is that of a mild eczema. 

Favus is, through its achorion Schoenleini, eminently con- 
tagious from child to child and from animal (rabbit, cat, 

28 



434 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

dog) to child, is communicated through beds, caps, and 
finger-nails, and is not confined to the head. A mild treat- 
ment may first be tried. Green soap and warm fomentations 
will succeed in removing the hard masses, and solutions of 
corrosive sublimate (1 : 100-300) and ointments of naphtol 
(5 per cent.) or pyrogallic acid (10 per cent.) may prove 
beneficial. Or a ten- (or less) per-cent. ointment of chrysarobin 
may be tried (according to Wolff) daily for six weeks, alter- 
nating it with a corrosive sublimate ointment (1 : 100). After 
that time, if the treatment have been tolerated, the application 
should be made every other day, and later once a week. The 
unguentum hydrargyri ammoniati will do the rest. I rarely 
saw a case improved without epilation, after a thorough 
removal of the yellow crusts by means of green soap and 
fomentations. Epilation can be done by pincers or by the 
old method of the pitch-cap, which is applied after the hair 
has been cut to one-third or one-half inch in length. Biedert 
modifies the old plan by melting two hundred and fifty parts 
of white pitch and four of tallow. The mixture is then 
spread over a cloth from six to eight square inches in size, 
which is fastened on the hair stumps with a hot iron and 
allowed to remain an hour before it is pulled off. This pro- 
cedure is repeated every six or eight days until the cranium 
is entirely bald and smooth. The pain can be overcome and 
the cruelty of the necessary process moderated by the use of 
an anaesthetic. Very obstinate places must be scraped out. 

Herpes tonsurans (from trichophyton tonsurans, a parasite 
very similar to achorion, common among domestic animals : 
circular vesicles, enlarging) requires a treatment similar to 
that of favus, including epilation. Before resorting to it, 
ointments of sulphur, ichthyol, salicylic acid, or chrysarobin 
may be tried. Corrosive sublimate (1 : 100) in solution and 
naphtol ointment are very efficacious. 

Mottuscum contagiosum (light nodes from which lobulated 



DISEASES OF THE SKIN. 435 

whitish masses containing brilliant oval bodies, perhaps pro- 
tozoa, can be squeezed out, mostly on the uncovered parts of 
the body) is very contagious and is met with epidemically. 
Communication from child to child or from baby to nurse 
must.be guarded against, the morbid growths removed with 
the sharp spoon, and the wounds treated antiseptically (best 
with carbolic acid) ; and, finally, if required, with balsam of 
Peru or ointments containing it. 

Lupus is in some of its forms (exfoliativus, tuberosus, ex- 
ulcerans, serpiginosus) accessible to anything but external 
treatment. Still, the treatment of the patient who, as a rule, 
shows more symptoms of scrofula than of tuberculosis is not 
excluded. Zinc chloride has been mixed with two or three 
parts of starch and made into a paste with water. Its appli- 
cation is very painful and its effect slow. So is Lannelongue's 
repeated injections of a ten-per-cent. solution of zinc chloride 
in water ; still more so Milton's indefinite and persistent use 
of carbolic acid and a twelve-per-cent. solution of hyperman- 
ganate of potassium (joined to the internal administration of 
arsenic, iodide of potassium, and mercury). Another method 
consists in the repeated application of saturated solutions of 
lactic acid ; still another is the use of the sharp spoon, and 
then for three or five days in succession that of a ten-per-cent. 
mixture of pyrogallic acid. Wherever the affected part is 
not too large, and in a convenient locality, excision ought to 
be made and the wound ligated ; should it be too large for 
that, transplantation may be performed afterwards. At all 
events, the destruction of the morbid part, wherever aimed at, 
is most easily accomplished by the actual thermo- or galvano- 
cautery. Tuberculin has failed here as in other cases of 
tubercular disease. A paste composed of arsenous acid 1 part, 
hydrarg. sulph. rubr. 3 parts, vaselin. 15 parts (or another 
menstruum), applied daily for several days in succession, has 
a deserved reputation for destroying the morbid masses. 



436 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

Tuberculosis of the shin (both verrucosa and ulcerosa) may 
be treated with the actual cautery and with mercurial plaster ; 
scrofuloderma (nodes in and under the skin of the face, neck, 
and extremities, with central softening and a cheesy pus), by 
arsenic internally and the sharp spoon, and subsequently iodo- 
form and balsam of Peru. 

Psoriasis, when acute, is a very distressing disease because 
of its intense itching. It requires many and protracted baths 
and plenty of soap to remove the scales ; unguentum hydrar- 
gyri ammoniati is used for the same purpose. Ichthyol oint- 
ment (five to ten per cent.) has rendered me good service in 
the only case I have seen for years. Neisser recommends 
chrysarobin or arthrarobin ointments (five to ten to twenty 
per cent.). They are positively dangerous in such doses, 
when used on children, because of the extensive erythema 
and conjunctivitis following them. On the head, therefore, 
he substitutes pyrogallic acid, but it dyes the hair black and 
is not so efficient. For chronic cases the principle of treat- 
ment is the same. The eruptions must be attended to locally ; 
ichthyol ointments will also do some good. Chrysarobin 
ointments (one to two per cent.), or chrysarobin in traumaticin 
in the same proportion, should be applied once every day or 
every few days. Green soap, or liquor potassii, will dissolve 
the scales and facilitate the effect of the other applications. 
Internally, iodides will prove effective in syphilitic cases. 
Thyroid in small doses (one to two grains daily) has had some 
successes among many failures. The best internal remedy is 
arsenic in long-continued moderate doses. 

A number of congenital diseases of the skin and subcutane- 
ous tissue are amenable to treatment; to them belong the 
neoplasms. Lipoma is found in two varieties : first, the circum- 
scribed and capsulated ; second, the diffuse. While the former is 
as easily removed as in the adult, the latter is sometimes inoper- 
able, inasmuch as it extends over large areas, and resembles 



DISEASES OF THE SKIN. 437 

in some instances, or in some parts of the anomalous growths, 
a moderate or formidable surplus of normal fat only. Fibro- 
mata, cysts, and dermoid cysts are met with ; many of them, 
though congenital, attract attention only after months or years. 
Atheromata (when small and superficial, embedded in skin only, 
— milia) are not infrequent about the head (eyebrows, etc.). 
They can be readily enucleated, and ought to be removed before 
they adhere to the skin and undergo suppuration. When they 
are suppurating, and removal very difficult or impossible, 
tartar emetic in water (1 : 30) may be injected, or hydrate of 
potassium introduced. Either of these will disintegrate the 
cyst wall to such an extent as to render their removal by 
pincers possible after a day or two. 

Congenital ichthyosis is not subject to treatment. It termi- 
nates fatally in a few days. Partial, follicular ichthyosis, in 
which bony spinse grow out of hair- and tallow-follicles with- 
out affecting the general health, demands frequent bathing, 
green soap, plenty of fat inunctions, and a ten-per-cent. sul- 
phur ointment. Congenital idiopathic atrophy of the skin 
(head, face, hands, feet) is not amenable to treatment. 

Congenital neoplasms on the neck are : hygromata (lymph- 
angiomata with albuminous contents and endothelia) ; serous 
and dermoid cysts, sometimes so dense as to render their diag- 
nosis from lymphatic tumors difficult when situated below and 
alongside the sterno-cleido-mastoid muscle; and sanguineous 
cysts, mostly diverticles of veins, or in a few cases rudimen- 
tary developments of the jugular vein. They require either 
enucleation or an extensive incision with aseptic tamponing. 

Nsevus pigmentosus and verrucosus belong here. Their 
treatment is similar to that applicable to vascular nsevi and 
tumors (p. 373), the latter differing from the former by a 
greater prominence of the skin, which is produced by elon- 
gation of the papillae and by hyperplasia of connective tissue ; 
also to the nsevus lipomatodes, which is a spherical or cylin- 



438 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

drical fatty excrescence covered with normal skin, sometimes 
pedunculated, sometimes sessile and with a broad basis. A 
few of the latter class are liable to grow out of proportion ; 
all the rest in conformity with, or even less than, the rest 
of the body. In the majority of cases the time for an opera- 
tive procedure is left to the medical attendant. Besides the 
methods of removal which have been detailed above, total 
extirpation is advisable in most cases. Indeed, it is the 
preferable method. Local anaesthesia can be easily accom- 
plished by a mild solution of cocaine (gr. J-2 : 100) sub- 
cutaneously administered. Excision is readily executed with 
but little loss of blood, and the sutured wound is covered 
with collodion. In a very few days, without a change of the 
collodion, recovery is apt to be complete. 



DISEASES OF THE EAR. 439 

XII. 

DISEASES OF THE EAE. 

Malformations of the ear, both external and internal, are 
mostly the results of arrests of development, and are but rarely 
amenable to improvement by treatment. A faulty position of 
the auricle may be corrected after birth ; when it protrudes 
unduly, bandages or adhesive plaster, worn for a number of 
weeks, will keep the organ in a more normal (adjacent) place. 
Obstruction of the auditory canal by either an epithelial or 
an organized membrane can be relieved ; the former demands 
a metal probe to perforate it ; the latter, a cruciform incision 
and removal of the flaps. 

Foreign bodies are common in all accessible cavities ; these 
prove frequent receptacles of shoe-buttons, pearls, peas, beans, 
etc. ; sometimes their removal is very difficult, particularly 
in the case of vegetables, which swell and thereby totally 
obstruct the meatus. The use of probes during examination 
is sometimes decisive in regard to diagnosis, sometimes very 
deceptive ; the reflector is indispensable. The secretion of 
secondary catarrh must first be removed by syringing and 
wiping ; pincers will remove a body which is not tightly in- 
carcerated ; a Daviel spoon, or the blunt end of a hair-pin 
bent upon itself, or a sharp spoon is often required for peas 
and beans. While the attempts at removal are going on, 
the ear ought to be frequently injected with warm water to 
expel shreds and blood and to facilitate inspection. Before 
the operation is begun, a cocaine solution may be instilled into 
the ear. A spray of ether may be demanded, and in urgent 
cases anaesthesia by chloroform ; for the extraction of a foreign 
body being paramount, even pieces of bone have to be removed 
sometimes to render its expulsion possible. 



440 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

Living bodies, such as insects, will die in water, oil, alco- 
hol, or a two-per-cent. solution of carbolic acid. Dried secre- 
tion, or cerumen, is softened by filling the ear with oil or 
glycerin and syringing forcibly with soap and water. The 
after-treatment may demand all the requisites of the therapy 
of inflammation, — rest, cool and disinfectant applications, erect 
posture, and narcotics. 

Otitis externa (inflammation of the external auditory canal) 
is the result of irritation by foreign bodies or by clean or 
dirty finger-nails, brushes, and sponges, also of the frequent 
use of ear-spoons, or of exposure to a high wind or draught ; 
or it may depend on eczema which extends inward from the 
neighboring surface. Gonococci and tubercle-bacilli have 
been met with in the external ear, diphtheria not infrequently, 
and soiled bathing water is probably a more common cause 
of ear-disease than is generally supposed. Now and then ex- 
ternal otitis complicates internal, particularly in infections 
diseases such as measles and scarlet and typhoid fevers. The 
general disposition to scrofula — that means to subacute or 
chronic inflammation of the tissues with rapid disintegration 
of the surface epithelium and insufficient tendency to repara- 
tion — is a frequent factor in the production of external ear- 
disorder, and requires constitutional treatment. Preventive 
local measures are indicated by the causes enumerated above. 
Foreign bodies must be looked for and, if present, extracted. 

The three forms of established external otitis are the ery- 
thematous, the catarrhal, and the phlegmonous (including the 
furuncular). The first exhibits a general redness, and produces 
scales rather than secretion. An occasional application of 
lead wash, or lead ointment, or zinc ointment, or bismuth 
subnitrate, finely powdered, will be all that is required in the 
average cases. Where the redness is marked and angry, with 
a good deal of itching, the ointment should contain five per 
cent, of cocaine ; or a watery solution of cocaine hydrochlo- 



DISEASES OF THE EAE. 4.41 

rate (two to six per cent.) may from time to time be brushed 
over the sore surface. 

The catarrhal form of external otitis is by no meaus a uni- 
form or always a mild affection. There may be pain, also 
secretion of a simply catarrhal or of a malodorous (fat acids) 
or cheesy nature. Erosions, ulcerations, and swelling of the 
neighboring lymph bodies are quite common. The integu- 
ment is sometimes greatly swollen and now and then granu- 
lating; below and behind polypoid excrescences the bone 
may be affected ; through the defective ossification anteriorly 
and inferiorly, fistulse may form in the parotid region and 
even in the maxillary joint, and pus may find its way through 
the incisure Santorini into the cartilaginous floor of the 
meatus. The drum membrane is frequently affected. Every 
form of myringitis is met with, from a slight hyperemia to 
thickening and turbidity of the membrane, even perforation. 
Thus there is every reason for early and persistent treat- 
ment. In the interest of examination, the speculum must not 
be used at first, except in older and very docile children ; it 
annoys, pains, and frightens, and is seldom as useful as in 
advanced age because of the horizontal position of the young 
drum membrane, only part of which, at best, can be seen. 
The secretion must be removed by syringing both frequently 
and forcibly (but the current must not be directed to the drum 
membrane) while the head is inclined so as to allow the in- 
stantaneous egress of the fluid. The injection fluid may be 
warm water, soap and water, salt and water (6-7 : 1000), or 
mild astringent solutions of acetate of lead, sulphate of zinc, 
tannin, or alum (1 or 2 : 200) ; or the secretion may be 
removed by tufts of absorbent, or borated, or salicylated 
cotton, which are held tightly in a pair of pincers and not 
rubbed hard against the wall of the canal. A saturated 
solution of boracic acid (four per cent.) is both mild and dis- 
infectant. Boracic acid finely powdered may be thrown in 



442 THERAPEUTICS OP INFANCY AND CHILDHOOD. 

so as to fill the canal after it has been thoroughly dried. 
When the renewed secretion has liquefied the powder, after 
a few or many hours, they are both removed by cotton or by 
injections, the ear thoroughly dried, and boracic acid intro- 
duced again as before. Bichloride of mercury (1 : 5000) in- 
jections may be given several times a day, mainly when there 
are much hyperemia and infiltration, in any of the varieties 
of external otitis ; fomentations of the same solution should 
be made persistently. Two daily applications of carbolic 
acid in glycerin (1 : 10-20) have also been recommended ; I 
believe they frequently irritate and fret the surface. Polypoid 
granulations have been removed by ligature. Chromic acid is 
liable to deliquesce so much, even when used carefully and in 
small quantities, as to endanger the drum membrane. The 
solid stick of nitrate of silver is safer, and requires for neu- 
tralization, after application, only a salt water solution. A 
daily touching with liq. perchlorid. ferri or liq. subsulphat. 
ferri is very effective and quite safe. Biedert recommends the 
sozoiodolate of hydrargyum. In external otitis leeches are 
seldom required, and then only where there is an excess of 
swelling. To relieve local pain and tension, cocaine solutions 
act better than do those of morphia. The oleate of morphia 
irritates the sore surface. Internally, a dose of morphia or 
some other opiate, or chloral, may become necessary. The 
patient must be kept in a semi-recumbent or almost erect 
position, on a cool pillow, in every catarrhal or inflammatory 
condition of the ear. Cases of external otitis with copious 
secretion, complicated with or dependent on eczema, are greatly 
benefited by one or two daily applications of a small quantity 
(well rubbed in) of bichloride of mercury in lanolin (1 : 300- 
500). In obstinate cases of eczema a solution of nitrate of 
silver (1 : 10-50) may be brushed over the parts once every 
few days. 

The phlegmonous form of external otitis is mostly recog- 



DISEASES OF THE EAK. 443 

nized with facility ; the pain is intense, the swelliDg marked, 
more or less local, circumscribed, and red. Before an incision 
— which ought to be made in time — appears advisable, appli- 
cations of solutions of hydrargyrum bichloride (1 : 5000 water) 
are better than warm fomentations. As stated, incision must 
be made soon, and will relieve quickly. The furuncular form 
demands at once either an incision or carbolic acid treatment. 
Both should be preceded by local cocaine anaesthesia, for the 
pain may be intense. The incision must be as thorough as 
in a furuncle of any other region. It may often be substituted 
by a thorough application of concentrated carbolic acid. If 
applied early, a single (or repeated) application will prove 
effective. As its action is quite local, there is no danger. 
If the furuncle be pointed and the point excessively painful, 
the acid ought to be introduced into the centre of the swelling 
by means of a slightly curved probe. 

Accompanying myringitis is apt to improve after its cause 
— the otitis externa — has been removed. A vesicatory or 
tincture of iodine on and about the mastoid process is helpful. 

Otitis media, both the catarrhal and the purulent variety, is 
a very frequent disease of infancy and childhood. Even in 
the middle ear of the newly-born accumulations are met with 
which either constitute or dispose to otitis. According to 
some, the masses frequently encountered consist of detritus 
developed out of the foetal epithelial covering ; others accuse 
aspiration during and immediately after birth ; some attribute 
the changes to oedema produced ex vacuo, the vacuum being 
due to the sudden separation of the mucous membranes for- 
merly immediately adjacent to each other. Infants have a 
large Eustachian tube, with a funnel-shaped pharyngeal aper- 
ture ; thus infectious material of the common eruptive fevers, 
strepto- and staphylococci, the bacilli of a diphtheritic rhinitis, 
and even gonococci find easy access. All the varieties of 
nasal, pharyngeal, and naso-pharyngeal catarrh, also adenoid 



444 THEEAPEUTICS OF INFANCY AND CHILDHOOD. 

vegetations and hypertrophied tonsils, are known to be the 
principal causes of middle-ear disease. Vehement spells of 
hooping-cough, forcible medicinal or other injections into the 
nares, and violent sneezing are apt to carry foreign mate- 
rial into the Eustachian tube and middle ear, particularly 
when the uvula is split in half (bifida), and still more 
so when the hard palate is fissured ; for in such a case the 
levatores palati have no support and the muscles of the tube 
are insufficient and atrophied. 

Preventive treatment has a wide scope. The number of 
cases of otitis media — according to Schwartze, twenty-two 
per cent, of all diseases of the organ of hearing are purulent 
forms of middle-ear disease — is as significant as its causes are 
manifold. Nasal, post-nasal, and pharyngeal catarrh must be 
attended to in their incipiency. Regular attention to the nose 
of infants would prevent much disease and many calamities. 
Indeed, defective hearing is more common than we suspect. 
Bezold found (1886) that of nineteen hundred and eighteen 
school-children, twenty-five per cent, had but one-third and 
eleven per cent, but one-fifth of normal hearing distance, and 
his statements have been amply confirmed. Most cases of per- 
foration of the drum membrane, chronic suppuration, abscesses 
in the mastoid process, permanent paralyses of the facial nerve, 
and cerebral abscesses can be prevented by treating and curing 
the origin and fountain-head of the future distress. The 
hypertrophied mucous membrane of the nose must be re- 
duced, adenoids removed, and enlarged tonsils resected in time. 
The interior of the nose ought to be washed — irrigated — at 
least once a day, according to known principles (p. 310). 
There is better reason, from the point of view of danger to 
health or life, for washing the inside than the outside. 

A child with an acute attack of middle-ear disease ought to 
be in bed, the head raised. The symptoms are not always 
urgent or easily recognized. In the very young the large size 



DISEASES OF THE EAR. 445 

of the tube facilitates the exit of the internal secretion into the 
throat, so that the drum membrane is not annoyed and pain 
from internal pressure and irritation is insignificant in many 
instances. Careful examination, however, will leave a doubt 
as to the actual seat in but few cases. A mild antipyretic, 
a small dose of a narcotic, or a purgative will ameliorate the 
symptoms. In the very beginning the Eustachian tube ought 
to be treated by inflation (Politzer) very carefully, if at all ; 
older children, who can be taught the use of Valsalva's 
method, must be warned against its excessive and vehement 
employment. When the acute stage has passed, both are more 
readily indicated. The severe pain may be relieved by a 
cocaine solution (2-10 : 100) instilled into the ear, also by one 
or more leeches to the mastoid process of the affected side, in 
most cases but one side being diseased. In mild cases tincture 
of iodine alone will suffice. When the drum membrane is red, 
a cloth moistened with a solution of hydrargyrum bichloride in 
water (1 : 5000), applied to the ear and frequently repeated, 
will, after getting warm, do equally as well as the most favored 
warm poultices. When secretion of mucus or pus is increas- 
ing inside, the posterior half of the drum membrane is pushed 
out first, afterwards the anterior ; between the two the hammer 
can be distinguished. A spontaneous perforation is apt to 
form in the anterior portion, but the presence of a white 
discoloration does not always indicate pus. When the pro- 
trusion of the membrane is very marked, an incision may be 
made, mostly posteriorly and inferiorly. The general opinion 
of experts, however, is no longer in favor of indiscrimi- 
nately early operation ; still, when it is performed, the incision 
ought to be sufficiently large. Pus is then expelled by in- 
flating through the nares (Politzer), and wiped out or carefully 
syringed out with a warm solution of table-salt or of boracic 
acid (3-4 : 100). The patient should rest on the diseased 
side. Boracic acid is then used as described in the rules laid 



446 THEKAPEUTICS OF INFANCY AND CHILDHOOD. 

down for its application in external otitis, or the cana. is 
gently syringed with a mild solution of bichloride of hydrar- 
gyrum, or of an astringent, — sulphate of zinc, acetico-tartrate 
of alumina (2:100-300). To what extent, during all this 
time, narcotics are to be used, or whether anaesthesia, local or 
general, ought to be employed, depends on the individual case 
and the judgment of the practitioner ; also whether an anti- 
scrofulous or anti syphilitic treatment (the latter but rarely in 
children) be demanded. Chronic discharges require politzer- 
ization frequently, though cautiously, and the use of boracic 
acid and astringents; secondary polypi, treatment similar to 
that detailed above. 

The secondary affections of the mastoid process demand 
leeches, ice, and tincture of iodine; where there is oedema, 
warm poultices and a deep incision. Abscesses of the mastoid 
process and of the brain require timely operation by an ex- 
pert hand. The general rules laid down by Troltzsch are 
still valid. Cerebral affections due to ear-disease are, when 
originating in the external meatus and the temporal bone, in 
the transverse sinus and the cerebellum ; when in the middle 
ear, in the cerebrum ; when in the vestibulum and cochlea, in 
the medulla oblongata. 

In my opinion, one of the most important additions to 
modern surgery is our knowledge of the operative accessi- 
bility of all the spaces and nooks of the middle ear, as taught 
by Schwartze, and of the epitympanic part, by Zaufal, in all 
cases of chronic suppuration of the middle ear accompanied 
by sensitiveness or suppuration on the surface of the mastoid 
process, or by fistulse, with osseous stenosis of the meatus and 
facial paralysis; of middle-ear disease exhibiting cerebral 
symptoms, with or without persistent fever, though there be 
no external inflammation ; also in cases of cholesteatoma of 
large size, with alarming cerebral symptoms during the opera- 
tion, particularly while injections are being made, or in those 



DISEASES OF THE EAR. 447 

in which sequestra or foreign bodies must be removed, mainly 
when they give rise to brain symptoms ; and, lastly, in cases 
of profuse ichorous secretion, or of actinomycosis, or of tuber- 
culosis of the middle ear. 

Deaf-mutism is rarely an affection of the organ of hear- 
ing. It would be better to assign it a place in connection 
with diseases of the nervous system, for most of both the 
congenital and the acquired cases result from cerebral affec- 
tions. It is not often hereditary. If more extensive statistics 
prove its (doubtful) dependency on consanguineous marriages, 
a wiser social hygiene can be made to act as a preventive. 
Alcoholism of the parents is a cause, and society and the state, 
with its organization of ignorance and disorder, are responsi- 
ble for so much of deaf-mutism as is not directly pathological. 
About half of all the cases are acquired, the majority of them 
through cerebral and cerebro-spinal inflammation. According 
to Biedert, fifty-five per cent, are of that class, twenty-eight 
per cent, depend on acute infectious diseases (typhoid and scar- 
latina, also variola and measles), 3.3 per cent, on traumatic 
injuries, and 2.5 per cent, on ear affections. Thus many of 
the congenital cases and most of the acquired are preventable. 
The treatment must be directed to so much of pathological 
change in the brain, the acoustic nerve, or the ear as is still 
accessible to the influence of either remedial or operative 
interference. 



448 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

XIII. 

, DISEASES OF THE EYE. 

Malformations of the eye are of different variety and 
gravity. Some cannot be corrected, such as cyclopia and mic- 
rophthalmia ; some need no correction, like the common (ver- 
tical) form of coloboma of the iris, or the congenital atresia 
of the pupil. The latter consists in the persistency of a part 
of the pupillary membrane originating from the posterior 
aspect of the lens, and, if still extant after birth, disappears 
slowly. Others require, and are corrected by, operations. 
Epicanthus — an abnormal accumulation of cutis near the root 
of the nose — may be removed by an operative procedure, in the 
event of its not gradually disappearing spontaneously. 

Neoplasms of the eye and eyelids are not frequent in infancy 
and childhood. Congenital nsevi of every variety, however, 
are not uncommon. Very superficial ones on the eyelids should 
be kept under observation. When uniform and rather pale, 
they are liable to heal spontaneously. When a net-work of 
enlarged blood-vessels is found on the lids or conjunctiva, 
there is often a central point the compression of which by 
means of a silver probe empties all the neighboring branches. 
This centre ought to be destroyed by a single application of 
the thermo- or gal vano- cautery, or by a trace of fuming nitric 
acid, or by running a silk ligature underneath and tying it. 
When they form small or large tumors, in most cases the 
actual cautery is easier and safer than the knife. The cautery 
must be used carefully and sparingly, — rather too little than 
too much, according to rules detailed above, — and always with 
a view of avoiding a consecutive ectropium. 

Dermoid cysts are found on the lids, inside ; also on the eye- 
ball; even in the orbit, from which their removal is rather 






DISEASES OF THE EYE. 449 

difficult. They must be enucleated when the diagnosis is un- 
doubted. They have been mistakenly diagnosticated in cases 
of encephalocele of the interior augle of the eye. 

Lipoma is very rare, still more so than cysticercus cellulosse. 
A few instances have been reported in which this cystic de- 
generation of the ovum of the tsenia solium was found in the 
posterior chamber and under the skin of the lid in children. 

Chalazion (not always tubercular, as has been asserted) is 
a mucous cyst in the tarsal cartilage, with a tendency to indu- 
ration. The eyelid is turned over, the small tumor incised, 
its contents scraped out, and iodoform applied once. As the 
wound is covered by the lid, it heals favorably. 

Glioma of the retina (Beer's amaurotic cat-eye) develops 
rapidly. Its vascular, sometimes red and bleeding, surface 
distinguishes it from suppuration of the vitreous body. It 
must be enucleated at once, as it is liable to grow rapidly in 
every direction. 

Syphilitic gummata have been observed in stray cases of 
retarded syphilis. They exhibit the symptoms of iritis, and 
require an antisyphilitic treatment. 

Tubercles of the iris are, fortunately, rare. They give rise 
to an incurable chronic iritis and necessitate enucleation of the 
eyeball. Tubercles of the choroid are sometimes observed in 
the incipient, sometimes in an advanced stage of tubercular 
meningitis. They are not amenable to successful treatment. 

Foreign bodies hidden under the eyelids must be removed 
speedily, for conjunctivitis will immediately follow their pres- 
ence. They are often washed out by the copious secretion of 
tears. The lower eyelid may be easily turned out and the cor- 
responding portion of the conjunctiva inspected. The upper 
requires turning up, which is more difficult because of the 
resistance of the child, but easier than in an adult, on account 
of the greater motility of the skin of the young eyelid. To 
facilitate inspection, the eye may be pressed gently backward 



450 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

into the orbit. The body, when seen, is removed by pincers, 
a fine sponge, a piece of gauze, or wiped off in the direction 
of the nose. In case of necessity, anaesthesia may be pro- 
cured by a drop of a two-per-cent. solution of cocaine. This 
is indispensable when the foreign body is in the cornea and 
demands instrumental removal. 

Injuries of the eye by puncturing, cutting, blows, etc., re- 
quire absolute rest, the removal of foreign bodies, the ap- 
plication of ice, of atropia solution (eserine when the wound is 
peripheric), and gentle pressure. Bad cases of laceration and 
destruction are either irremediable or require special, perhaps 
operative, treatment. 

The eyelids suffer from blepharitis mostly in scrofulous 
children, in whom dust, smoke, and infections of all kinds are 
apt to thoroughly influence the superficial tissues. It often 
accompanies eczematous eruptions of the head and face, and is 
frequently carried by the fingers. Therefore, soap and water, 
a nail-brush, and cutting the nails short are good prevent- 
ives ; so is the successful treatment of the head and face. The 
blepharitis and conjunctivitis of measles require no special 
local treatment ; the common forms do well with a zinc oint- 
ment, or one of the yellow oxide of mercury with vaseline 
(1 : 50-100). The secretion must not be permitted to get dry. 
Hard crusts are dissolved by a warm solution of carbonate of 
sodium (1 : 100-200) or by frequent washing with soap and 
water. Grave cases demand epilation of the eyelashes, every 
one of which — so far as required — must be caught singly and 
drawn out slowly enough to secure removal of the entire hair. 
Ointments and solutions of lead it is best to avoid, for com- 
plications with corneal erosions, grave or slight, are very 
frequent in affections of the eyelids and conjunctiva, and even 
the slightest ones will be indelibly stained by lead salts. 

Both the integuments and the connective tissue of the eye- 
lids being of loose structure and expansible, oedema is quite 






DISEASES OF THE EYE. 451 

frequent. Insect bites are mostly diagnosticated by their cir- 
cumscribed and pointed appearance ; cardiac and renal diseases 
have their own indications ; so has hydremia from whatever 
cause, besides the indications for the administration of iron, 
quinia, or arsenic. 

The conjunctiva is very liable to be affected by medicinal 
and poisonous agents. According to Silberman, aniline, potas- 
sic chlorate, and corrosive sublimate produce thrombosis ; pun- 
gent gases, conjunctival hyperemia and conjunctivitis; anti- 
pyrin, urticaria of the eyelids ; arsenite of copper, redness 
and corrosion ; arsenide of hydrogen, a brownish-red or icteric 
discoloration ; bromide of potassium, simple or phlyctenular 
conjunctivitis, without, however, influencing the blood-vessels 
of the interior ; chrysarobin, a local inflammation ; coniin, a 
burning sensation ; ergotin, hemorrhages ; iodide of potassium, 
inflammation ; iodoform, when applied locally, an erysipelatous 
tumefaction ; and salicylate of sodium, oedema and a bluish ex- 
anthem ; in larger doses, tumefaction and vesicular eruption. 
Still, cases of conjunctival disease depending on these agents 
are comparatively rare. 

The majority of the diseases of the conjunctiva are of an 
inflammatory character. In a number of cases of conjunctivitis 
the conjunctiva of the bulbus does not extensively participate. 
Common forms of fevers, also hooping-cough and princi- 
pally measles, are among the causes of acute conjunctivitis. 
Sometimes there is but little redness ; the lids are thickened 
and stiff with oedema. In other cases there is plenty of mucus, 
sometimes purulent, now and then with a tendency to coagu- 
lation, but not to such a degree as to render difficult the dif- 
ferential diagnosis from diphtheria of the eyelids. The mucous 
secretion must be wiped off with absorbent cotton or a moist 
cloth, boracic acid solution of three per cent, should be ap- 
plied or instilled, and cold water employed at intervals of from 
one to ten minutes ; chlorine water, if to be had fresh (a tea- 



452 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

spoonful in a glass of water), should be used for applications; 
if the surface secretes much, corrosive sublimate (1 : 4000- 
5000). If the secretion be purulent, nitrate of silver, 1 part 
in 100 or 500 parts of distilled water (black bottle), must be 
applied once a day, best with a brush, and washed off with 
pure water. A high degree of congestion, with phlyctenular 
eruptions, — sometimes unilateral only, not infrequently com- 
bined with blepharitis, — demands persistent application of 
cold, best by keeping a number of small pieces of cloth on a 
lump of ice and applying them at short intervals until they 
begin to get warm. Atropise sulphas (1 : 200-500) should be 
instilled once or twice a day, and the lids kept at rest. To 
hold them immovable, if the patient be very young, a layer of 
absorbent cotton should be covered with, or slightly soaked in, 
collodion and applied after the eye has been wiped dry. Later 
an ointment of the yellow precipitate of mercury (1 : 50-100), 
or calomel finely powdered, may be employed once a day. 

Chronic conjunctivitis presents in many cases but few symp- 
toms. The superficial hyperemia does not always correspond 
with the burning sensation often complained of, and the mu- 
cous secretion is but trifling, and collects mostly in the inner 
angle of the eye. Overexertion of school-children, particularly 
those who are hypermetropic or astigmatic, diseases of the 
nose of a catarrhal or ulcerous nature, indigestion and con- 
stipation, anaemia, scrofulosis, or trichiasis are just so many 
causes and require the appropriate causal treatment, both 
medicinal and hygienic, change of air (country), and cool and 
cold bathing. These measures often suffice to relieve even 
secondary disorders of the lymph circulation, which is easily 
disturbed. Like the orbits which discharge their lymph ducts 
into the deep facial lymph bodies, those of the lids and con- 
junctivae are emptied into the glands of the aural and sub-* 
maxillary regions. The medicinal treatment is disinfectant 
and astringent ; the remedies must be changed from time to 



DISEASES OF THE EYE. 453 

time. Sulphate of zinc (1 : 250-500) with or without cocaine 
muriate (1-2 : 100), in more protracted cases ointments of sul- 
phate of zinc or sulphate of copper (1 : 100-150), solutions 
of boracic acid (3 : 100) or of sodium carbonate (1 : 100-200), 
in suppurating cases a daily brushing with nitrate of silver 
(1 : 250-1000), combined with scrupulous cleanliness and 
avoidance of vascular stimulants, will meet all indications. 

The chemosis of scleral conjunctivitis does not require any 
additional applications ; mild astringents and rest will suffice. 
Rubbing, constipation, and coughing result in hemorrhagic dis- 
coloration (general blueness or extravasations) which requires 
rest and cool (or warm) fomentations. 

Diphtheritic conjunctivitis cannot readily be mistaken. The 
infiltration is hard and the pseudo-membrane not removable. 
There is no secretion ; indeed, the eye is dry to such an extent 
that the pressure of the exudation alone ulcerates the cornea. 
Absolute caution in every case of — particularly nasal — diph- 
theria, and covering the healthy eye, when (as usual at first) 
but one eye is affected, with a cotton and collodion application, 
aided by more cotton and a bandage, are indispensable. 
Thorough and speedy mercurial ization and antitoxin are 
indicated. Papayotin (1 : 5-10 of water and glycerin), not 
to be substituted by " papoid," must be applied every hour. 
Nitrate of silver deserves no recommendation. Chlorine 
water, carefully applied while the eyelid is kept away from 
the eyeball, whenever that is possible, may render good ser- 
vice. Ice must be applied carefully and persistently. 

Most cases of gonorrheal conjunctivitis are contracted during 
birth from the gonococcal discharge of the maternal vagina ; 
others through handkerchiefs, towels, fingers, or bathing water. 
Its treatment has been discussed (p. 64). 

Trachoma, possibly of a microbic, surely of a specific char- 
acter, consists of granular deposits and proliferation of cells 
which crowd upon the normal tissue and render it atrophic. 



454 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

Its duration is long ; its treatment must be persistent. The 
acute attack, or stage, requires daily brushing with nitrate 
of silver (1 : 100), and washing off with water when the first 
effect of the caustic becomes visible. The subacute cases de- 
mand a daily (or less frequent) application of the sulphate of 
copper stick. The granulations may also be scarified, scraped 
out, or squeezed out, — an old operation successfully re-estab- 
lished by modern surgery. Many cases do well with a daily 
application of one part of bichloride of mercury in one thou- 
sand parts of distilled water. The conjunctival duplicature, 
which is the pet seat of trachoma, has been excised to get rid 
of a large part of the diseased masses at once. For domestic 
treatment, an ointment of sulphate of copper and vaseline (1 : 
100), with or without cocaine muriate, will prove beneficial. 
A similar treatment, somewhat modified and diluted, is ap- 
plicable to what is described as granular conjunctivitis, which 
probably is in no case anything but a mild form of trachoma. 
Follicular conjunctivitis is probably of the same nature in 
many cases ; usually it is described as an inflammation of the 
(microscopically small) glands of the conjunctiva. The folli- 
cles are in rows near the margin of the eyelids. It is com- 
plicated with, or depends on, the presence of foreign bodies, 
of nasal disease, or of other varieties of conjunctivitis, and 
is not infrequently found in large numbers in families and 
schools. The treatment is milder than that of the previous 
forms, — rest, washing, boracic acid solutions, astringents. 

Keratitis, beginning with a small vesicle, which is mostly 
not observed, and rapidly terminating in a superficial ulcer- 
ation, is frequently met with in "scrofulous" children, who, 
besides, suffer from affections of the mucous membranes of 
the nose, lips, and ear, from eczema, glandular tumefactions, 
etc. Some patients are rickety. To overcome the spasm of 
the conjunctiva, cocaine is often required to facilitate examina- 
tion ; for that purpose the dipping of the head into cold water, 



DISEASES OP THE EYE. 455 

a popular remedy for photophobia, is probably not convenient. 
The constitutional disorder must be combated by cleanliness, 
fresh (country) air, bathing, plain and nutritious diet, quinia 
in small, iodide of iron in proper doses. Iodide of potas- 
sium in small doses (gr. i-ii), three times a day, given for a 
long time, is very successful in many cases. The room must 
be kept moderately dark and the eye protected by a shield. 
Good local applications are chlorine water diluted in from 
twenty to one hundred parts of water, corrosive sublimate 
(1 : 5000), boracic acid (3 : 100), atropia solution of one half 
per cent., or cocaine solution of two per cent, (the last two 
occasionally in combination). When the ulceration is near the 
corneal margin, eserine is recommended in place of atropia ; 
but it is advisable to remember that it produces a congestion 
of the iris and may predispose the latter to be drawn into the 
morbid process. Old cases will do well with occasional (one 
every day or two days) gentle applications of nitrate of silver 
(1 : 200-500) or (particularly when the conjunctiva is pale) 
of finely powdered calomel ; this latter has always been highly 
recommended, and is useful, if persistently used through weeks 
and months, when turbidity of the cornea remains behind. 
Old cases with defective power of reparation will do well 
when the lids and eyeball are gently kneaded with an oint- 
ment of the yellow precipitate of mercury (1 : 50). In many 
instances some of these remedies will act better than others ; 
alternation is often required. A simple ulceration, no matter 
what application is employed, will heal better, or best, by 
avoiding friction of the eyelids ; they ought to be immobil- 
ized by cautious bandaging, which may be removed to make 
the demanded local applications. Under the bandage a cloth 
wet with a solution of corrosive sublimate (1 : 5000) or boracic 
acid (3 : 100) will prove quite acceptable and beneficial. Sup- 
purating ulcerations lead to hypopyon and perforation. They 
require, besides atropia, or eserine when near the margin, occa- 



456 THERAPEUTICS OP INFANCY AND CHILDHOOD. 

sional applications of corrosive sublimate (1 : 2000) or nitrate 
of silver (1 : 100). Biedert recommends cocaine and scraping 
or burning of the abscess. According to him, the main obsta- 
cles in the way of speedy recovery are: complications with 
conjunctivitis, blepharitis, nasal affections, stenosis of the lach- 
rymal duct and blennorrhea of the lachrymal sac (but rarely 
its congenital obstruction), and blepharophimosis with photo- 
phobia and rhagades. 

Parenchymatous or diffuse keratitis is a peculiar variety. 
The turbidity and thickening of the two cornese (the process 
being bilateral) are extensive, not always uniform, often dis- 
seminated, and complicated with considerable vascular injec- 
tion on and around the cornese and with synechia of the iris. 
Very many cases of this variety — according to some, the vast 
majority ; ninety-six per cent., according to Parinaud ; thirty 
per cent., according to Siklossy — are the results of syphilis, 
either hereditary, or acquired, or retarded hereditary. They 
require persistent antisyphilitic treatment with iodide of 
potassium (and mercury). Scrofula, rhachitis, malaria, and 
arthritis are also charged with producing this form. It is 
certainly true that iodine and mercurial treatment are not 
always successful. Some cases are benefited by salicylate of 
sodium. Atropia is useful in all. 

In neuro-paralytic keratitis both the conjunctiva and the 
cornea are deprived of sensibility, the lids do not move, the 
eye is kept open, the cornea is dry (xerosis) and may undergo 
softening (kerato-malacia), with the result of either perforation 
or incurable turbidity and local thickening. It is met with 
in severe infectious fevers, particularly during the unconscious 
state of typhoid, and in the coma of encephalitis. These 
results are not often met with for a long time in succession, 
for most of the patients die of the original disease. They 
have also been noticed during and after frontal and con- 
junctival herpes zoster. In all these cases the eyeball must 



DISEASES OF THE EYE. 457 

be moistened with salt and water (6-7 : 1000) and the lids 
closed by a bandage or by cotton with collodion. In most 
cases the latter will prove as effective as suturing of the 
two eyelids. Xerosis of the conjunctiva is also noticed, in 
very young infants, as the result of ill nutrition and consecu- 
tive marasmus. Most of the patients are from two to six 
months old. Proper and sufficient food will sometimes re- 
store both the eye and the general health, but the mortality 
of these cases is very high. The same condition is found in 
children of from three to nine years (Thalberg, Forster). 
Several such cases were complicated with hemeralopia. 

Keratoconus — the conical raising of the centre of the cornea — 
requires a cautious thermo- or galvano-cauterization ; pannus, 
the centre of which is generally absolutely deprived of blood- 
vessels, demands stimulation. Daily insufflation of finely pow- 
dered calomel, continued for weeks or months, has met with 
some successes. Infection with erysipelas and gonorrhoea has 
been observed to restore circulation and absorption, and the 
latter has been utilized, consequently, to accomplish these ends. 

Acute iritis is rare in infancy and childhood ; its complica- 
tion with glaucoma still more so. Of its two great causes, 
syphilis is almost exclusively of the hereditary variety, and 
rheumatism exhausts its main danger in starting endocarditis. 

Chronic iritis is not often seen in early life, except in con- 
nection with diffuse keratitis. The treatment of iritis is 
essentially identical with that of the same affection in adults : 
hydrargyrum, iodides, and salicylates, according to the causal 
indication ; instillations of atropise sulphas in distilled water 
(1 : 100-500) from two to ten times a day, or oftener if the 
danger of adhesion be imminent, with a two-per-cent. solution 
of muriate of cocaine if the pain be great ; absolute rest in 
the acute variety ; dry heat ; a dark room ; iridotomy, or 
rather iridectomy, in most cases to loosen synechise and restore 
a pupil. Subconjunctival injections of corrosive sublimate 



458 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

(1 : 1000, a few drops at a time) were used by Darier in 
1892, and in Deutschmann's clinic. They are made near the 
margin of the cornea and downward, and are recommended 
principally for syphilitic affections of any part of the eye, 
except, perhaps, the optic nerve. Parenchymatous keratitis 
and iritis are also said to be amenable to the same treatment, 
though they be not syphilitic. Later reports are not quite so 
favorable. 

Suppurative cyclitis and a true abscess of the vitreous body 
are generally found together. Blindness is imminent, and 
enucleation to save the other eye becomes a necessity in almost 
every case, except in small children. In them the process has 
often exhausted itself, and terminates in blindness and con- 
traction without secondary irritation. When the abscess is 
small, part of it may be absorbed, and a white cloud in the 
lower part of the vitreous body, and feeble vision, may be 
the only evident results. 

Uncomplicated inflammation of the choroid is rare in chil- 
dren. Idiopathic choroido-retinitis is observed in later years 
in both eyes after it has lasted a long time. It certainly com- 
mences at an early age, but takes decades before it ends in con- 
traction of the field of vision, degeneration of the retina and 
optic nerve, and turbidity of the vitreous body and the pos- 
terior capsule of the lens. In all cases, whether syphilitic or 
not, treatment with mercury and iodides is the only one either 
reliable or advisable. 

Congenital cataract demands an operation if vision be in- 
sufficient. If it be partial, atropia and iridectomy will suifice. 
Total cataract is rare in early years ; more frequent is zonu- 
lar cataract, which exhibits round its nucleus one or more 
turbid layers, followed by normal clear ones. As at the same 
time in a number of cases transverse phosphatic deposits are 
found in the teeth, zonular cataract has been attributed by 
many to rhachitis ; others connect it with convulsive dis- 



DISEASES OF THE EYE. 459 

eases. Some constitutional disorder has been charged with 
being the cause, but no treatment has been advised, nor is 
there any apparent indication, except to correct the accom- 
panying myopia. 

Diseases of the retina, the optic nerve, and the orbit show 
no particular symptoms in the young, nor do they require 
special treatment different from that employed in advanced 
age. In many cases of acute or chronic leptomeningitis with 
ample effusion, blindness depending on copious secretion in 
and around the tissue of the optic nerve is an early symptom. 
Early diagnosis of this condition, and treatment with mercury, 
iodides, and derivants (diuretics, purgatives, diaphoretics), 
may succeed in reducing the oedema and preventing compres- 
sion and atrophy of the nerve. A number of such cases will 
get well. 

The tissues of the young eye being soft and elastic and ex- 
pansible from internal pressure, glaucoma is but rarely seen at 
an early age. Its place is taken by hydrophthalmos (buph- 
thalmos), which requires the operative procedures employed 
for the glaucoma of advanced age, — either iridectomy or 
sclerotomy. 

Strabismus is common in infants. In them it is the result 
of an insufficient development of muscular power in general 
and of accommodation. It requires no treatment. That 
which makes its appearance during convalescence or in gen- 
eral hydremia terminates in recovery. Diphtheritic paralysis 
of the muscles of accommodation recovers spontaneously, or 
through generous feeding and the administration of iron and 
strychnia. Muscular paralyses resulting from cerebral dis- 
eases depend on these for their treatment. 



460 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

XIV. 

DISEASES OF THE MUSCLES. 

Acute inflammation of the muscles — myositis — is located 
either in the external or internal perimysium, also in the 
contractile elements. Cellular infiltration, coagulation, fatty 
and hyaline degenerations, suppuration, nuclear proliferation, 
and the formation of new connective tissue are observed 
as its morphological changes, with either incurable retrac- 
tion or curable contraction as their results. Traumatic myo- 
sitis (see p. 48) requires absolute rest, the application of 
cold water or ice, after a while tincture of iodine once a day 
or every other day, iodide of potassium and lanolin ointment 
several times a day, or gentle massage without the ointment. 
Iodide of potassium internally is indicated when thickening 
remains behind. If, after a long time, the muscle, though 
without pain, does not become normal, the electrolytic effect 
of the galvanic and the stimulating action of the interrupted 
current, in short sessions, will improve the condition. Both 
traumatic and rheumatic myositis have a tendency to relapses. 
The latter requires a treatment similar to that which has been 
detailed above, with this exception, that hot (dry) applications 
generally render better service, and the internal administra- 
tion of salicylate of sodium is mostly indispensable. Inunc- 
tions of oil of wintergreen are often useful, as are also dia- 
phoretics. The infectious myositis of eruptive and septic fevers 
starts an effusion which is either serous or purulent, and re- 
quires accordingly, besides the active attention demanded by 
its origin, either expectant or operative (and antiseptic) treat- 
ment. Syphilis produces either gummata or hyperplasia, and 
demands, in addition to internal specific treatment, either the 
inunction of an oleate of mercury or of the blue ointment, or 



DISEASES OF THE MUSCLES. 461 

subcutaneous injections of the bichloride. Tubercular deposits 
are caseous and purulent ; they must be incised, scraped out 
and irrigated, and the cavity filled with iodoform gauze. 
Purulent myositis is hardly ever idiopathic, and its cause 
or complications must be ascertained (syphilis, tuberculosis, 
sepsis). 

The chronic forms of myositis met with in children are, as 
a rule, outgrowths of the acute inflammation. The rare 
forms of traumatic ossifying and that of petrifying myositis are 
hardly ever seen in childhood, with the exception of the occa- 
sional appearance of the multiple progressive ossifying variety, 
— a collateral to the cartilaginous exostoses, — which exhibits 
inflammation and bone-formation in the cellular tissue of the 
fascise, in the aponeuroses, and in the tendons of the back, 
the chest, the masseter, and the extremities. It is sometimes 
complicated with defect or anchylosis of the phalanges of the 
thumb. It is a nutritive disorder always of congenital origin. 
No available treatment is known. 

Ischsemic muscular paralysis is the result of anaemia (mostly 
local, as from the influence of cold). The pain, loss of elas- 
ticity, and resulting contracture require massage, gymnastic 
exercise, and electricity. 

Tropho-neurotic ill nutrition and paralysis comprise two 
varieties. One is the result of inflammation of a joint : 
from disuse the neighboring muscles become atrophic and 
more or less paralyzed. The other originates in a change of 
the spinal centres, as in poliomyelitis, with fatty degeneration 
and atrophy as inevitable consequences. 

The "pseudo-paralysis" of rickety children is simply debility. 
Muscular atrophy, progressive juvenile muscular dystrophy, and 
pseudo-hypertrophy have been mentioned above (p. 378). 

The affection which has been described as grave pseudo- 
paralytic myasthenia, and which consists in a peculiar ex- 
haustion 6*f the muscles on slight exertion, to such an extent 



462 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

as to render voluntary contraction very difficult and to rapidly 
diminish electrical excitability, appears to depend either on 
defective innervation or on chemical changes. In the single 
case I have seen, massage aud strychnia rendered some service. 
Yeratrin, physostigmin, and digitoxin are recommended. 

Torticollis (caput obstipum) means a contraction of the 
sterno-cleido-mastoid muscle, mostly its sternal end ; the head 
is turned to the affected, the face to the opposite side, and the 
diseased side is not infrequently more or less atrophic. The 
treatment depends to a great extent on the cause of the con- 
traction. Malposition in the uterus is an occasional direct 
source, as also the hematoma originating during birth, or later, 
which has been mentioned elsewhere (p. 48). Tumors, such as 
sarcomata, have the same influence on the function of the muscle. 
This is impaired, in advanced childhood, by sudden strains ; for 
instance, by kite-flying, by loads carried on one shoulder, occa- 
sionally also by an abnormal position of the head enforced by 
paralysis of the ocular muscles, in order to avoid double vision 
(Landolt). Rheumatism of the muscle, isolated or more gen- 
eral, and of one or more vertebral articulations, has the same 
effect. Salicylate of sodium internally, oleum gaultherise, and 
ammoniacal or camphor inunctions will do good. The same 
may be said in regard to muscular rheumatism in general. 
Torticollis is also one of the symptoms of the acute rheuma- 
tism of the neck which, because of its serious symptoms 
(fever, vomiting, delirium, with no irregularity, however, of 
the pulse), has been mistaken for meningitis. Sometimes it 
depends on a neurosis (neuritis ?) of the accessory nerve. In 
that case the scalenus and trapezius muscles are also affected. 
Reflex torticollis has been mentioned in connection with intes- 
tinal worms and with carious teeth, and an intermittent form 
is known to exist (Forchheimer) depending on malaria. In 
these cases quinia and arsenic are indispensable. Worms must 
be removed, teeth corrected. In those cases in which heavy 



DISEASES OF THE MUSCLES. 463 

loads carried on one side cause contraction of the other, a sys- 
tematic use of the diseased side will restore the equilibrium. 
Exaggerated and forcible swinging of the arms will secure co- 
operation and exercise of the muscles of the neck. Massage 
both of the muscles and of the articular processes of the cer- 
vical vertebrse from the third to the fifth is required. The 
galvanic current in mild doses relieves spasm. Gentle rubbing 
with lanolin (in inflammatory cases with iodide of potassium 
or mercury) is beneficial. Cold temperatures must be avoided. 
Otherwise unconquerable cases require tenotomy, to be per- 
formed from inside outward. 



464 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

XV. 

DISEASES OF THE BONES AND JOINTS. 

Of the congenital malformations of the extremities (bones 
and soft parts), many are not accessible to treatment. To this 
class belong arrests of development and spontaneous ampu- 
tations. Curvatures of the limbs (congenital, through fracture 
of the tibia) may require osteotomy or osteoclasy ; but their 
domain is not very extensive, for in the large majority of 
acquired rhachitical curvatures of the legs recovery takes place 
spontaneously. Observations in the surgical clinic of Tubin- 
gen, extending over a number of years, prove that seventy- 
five per cent, of all such curvatures will straighten out in 
from two to four years. When the patients were first pre- 
sented, plaster-of-Paris casts of the deformity were made, 
and another examination took place after an average of 
four and one-half years. Improvement was noticed in 15.3 
per cent, additional. In 9.7 per cent, only no spontaneous 
recovery or improvement took place. It is in these that op- 
erations are demanded. Supernumerary fingers and toes are 
either removed from their cutaneous attachments or extirpated 
from their sockets. Congenital enlargements of toes, consist- 
ing in hypertrophy of both bone and fat, are removed by 
amputation. If their relationship to acromegaly could be 
established, thyroid treatment might find one of its successful 
fields of action. Synechia of (webbed) fingers and toes must 
be separated ; the operation being difficult, it is best to delay 
it for some time, but not long enough to endanger the growth 
of the organ. 

Congenital luxation of the hip-joint, with the exception of 
rare cases depending on injuries contracted during birth, is the 
result of an arrest of development of the acetabulum, which is 



_ 



DISEASES OF THE BONES AND JOINTS. 465 

sometimes hereditary and now and then complicated with other 
malformations. The head of the femur finds no accommoda- 
tion, and the trochanter is found above its normal place. This 
is particularly so on the steep os ilium of the female. When 
the luxation is unilateral the gait is limping ; when bilateral, 
waddling. Extension lengthens the extremity and conceals 
the deformity. Treatment is either mechanical or operative. 
E. N. Bradford {Annals of Surgery, August, 1894) claims 
that no cure is effected by any methods of treatment by trac- 
tion or by mechanical means, even with tenotomy, that cor- 
rection by forcible reduction is not reliable, and that operative 
reduction is more promising, but risky. In the same number, 
T. Halsted Myers promulgates more favorable opinions. He 
favors, first, mechanical reduction ; then, for the purpose of 
inducing the new formation of connective tissue and cicatriza- 
tion, subcutaneous injections of chloride of zinc. If they be 
insufficient, an operation, according to Hoffa (whose operations 
up to that time showed a mortality of 3.3 per cent.) and 
Lorenz, is advisable. Until a few years ago the mechanical 
treatment was the only one generally recommended. Volk- 
mann relied on permanent extension, particularly in unilateral 
cases. Schede uses splints, with pelvic support, to extend and 
to abduct the extremity, for from two to four years in suc- 
cession. He fiuds the indication for this treatment in bi- 
lateral cases up to the fourth year, in unilateral cases up to 
the eighth or ninth, for the rudiment of the acetabulum 
whose size can be improved upon frequently persists up to 
that period of life. Pavi lost a girl of seven years (of dj's- 
entery) four months after reduction and extension of her 
bilateral dislocation. At the autopsy he found two new joints 
which appeared to promise stability of the femoral head in 
the new position, if the child had lived. Within a short time 
the results of operations have become very favorable. In the 
German Congress of Surgeons of 1894, Lorenz — in that of 

30 



466 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

1895, Hoffa — presented very satisfactory statistics and pa- 
tients. Neither of them cuts the muscles, but both reduce 
the dislocated limb by powerful extension. The incision is 
longitudinal, like that made for resection ; the capsule and 
soft parts are loosened from the trochanter by subperiosteal 
operation, the acetabulum is enlarged and the head fitted 
into it. The superfluous capsular tissues are then extirpated, 
the wound is filled with iodoform gauze, and an extension 
apparatus applied. The extremity begins to grow, shortening 
becomes less, and head and acetabulum gradually increase in 
size. Hoffa's operations were performed between the second 
and eighth years. He presented the statistics of one hundred 
and twelve operations performed on eighty-two patients with- 
out cutting muscles. The last forty-seven terminated without 
a death. 

Lately, A. Lorenz * has published his objections to the pro- 
tracted employment of extension, which keeps the patient in a 
recumbent position, possibly for years, and interferes with the 
nutrition and function of the limb or limbs. Instead, he ex- 
tends forcibly, under anaesthesia, and reduces the head of the 
femur, the reposition being kept up by strong abduction. The 
head of the femur is then retained in the small acetabulum by 
apparatuses and the abduction is gradually diminished. After 
a while standing and walking are permitted. At first, while 
abduction is continued, these movements are clumsy and dif- 
ficult, but when the weight of the body and the constant 
friction have deepened the acetabulum, they become easier by 
degrees. The oldest child in whose case this procedure was 
successful, the luxation being bilateral, was six years and 
three months. In one case of unilateral luxation, standing 
and walking were interrupted three days only, in others sev- 
eral weeks. Even when the luxation was bilateral they were 

* Centralblatt f. Chir., 1895, No. 33. 



_ 



DISEASES OF THE BONES AND JOINTS. 467 

not long delayed. Two patients were able to stand after six 
weeks. 

A number of cases described as chronic articular rheumatism 
are undoubtedly those of arthritis deformans. Their merely 
antirheumatic treatment is, therefore, inefficient. The differen- 
tial diagnosis is perhaps best made by noting the early changes 
which take place in the skin and the rest of the epidermoid 
tissues and in the muscles. The accompanying changes in the 
muscles, — a slowly progressive atrophy with corresponding 
paralysis, without reaction of degeneration, and with only so 
much alteration of electrical and galvanic excitability as is 
explained by the atrophy of the muscular tissue, — trophic 
changes of the nails of fingers and toes (thickening, fragility, 
and exfoliation), and those of the skin (vitiligo and chloasma 
and slight indications of scleroderma, even ichthyosis in a 
few instances*) appear to prove their great difference from 
rheumatism and their intimate connection with the nervous 
system (p. 379). 

Multiple infantile exostoses are congenital, sometimes heredi- 
tary ; develop early, now and then only after puberty ; grow 
near the periepiphyseal cartilage, between epiphysis and dia- 
physis, sometimes from the very cartilage of the epiphysis ; are 
now and then found on scapula, pelvis, and cranium ; grow in 
rare instances even after the completion of the growth of the 
body ; remain cartilaginous or become osseous, and then may 
interfere with the growth of the bones. They do not often dis- 
turb the functions of the long bones and joints, but the ulna has 
been known to become crippled by them, the skin may ulcer- 
ate over them, and the synovial capsule may be raised by one 
growing too near the joint. These complications sometimes 
require special treatment and attention. Exostoses, so long 
as they are but few and not cumbersome, are best left alone. 

* Curschmann in Schmidt's Jahrb., 1895, No. 8, p. 220. 



468 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

However, in the next case of early age seen by me I shall 
give phosphorus (p. 102) systematically, for the purpose of 
enforcing speedy ossification, both local and general. Extir- 
pation is indicated when there are but few, and when these 
are large ; but the neighborhood is replete with blood-vessels, 
and the operation and after-treatment demand unusual care to 
avoid ostitis. Iodide of potassium has been administered 
extensively. 

Fractures heal the more readily the younger the patient. 
Callus is speedily formed, and, the muscles being feeble, dis- 
location of the ends of the bones does not take place to any 
considerable extent. The fracture of the humerus occasioned 
during birth requires a light splint with but little wadding. 
A piece of pasteboard and a few strips of adhesive plaster or 
a bandage, and the support of the limb either by a sling or by 
fastening it to the body, are sufficient. Clavicles heal readily 
when tied up in a triangular cloth, the arm being fastened to 
the body. Where moistening by urine, etc., is feared, the 
gauze bandages should be soaked in collodion. 

Perichondritis and osteochondritis occur, of course, in earliest 
infancy only, mostly under the influence either of rhachitis or 
of syphilis, most frequently in the forearm and the leg, also 
on the ribs or clavicles, and terminate either in cutaneous in- 
filtration or disruption of epiphyses. Pain is rare, and the 
" pseudo-paralysis" of Parrot means but the functional dis- 
turbance due to infiltration of the tissues. Periostitis, ostitis, 
and osteomyelitis are due, in the first instance, to the disposition 
created by the activity of metamorphosis and by the physio- 
logical succulence of the bones, whose growth starts from the 
periosteum, from the marrow, and from the periepiphyseal car- 
tilage. The vulnerability of general scrofula and hereditary 
influences add to their liability to become diseased. Proximate 
causes of inflammation are trauma, colds, infectious diseases 
such as hooping-cough and measles, and the invasion of 



DISEASES OF THE BONES AND JOINTS. 469 

cocci and bacilli. The termination of periostitis is either in 
absorption, or thickening, or suppuration. In "albuminous 
periostitis" pus is substituted by serum and fat. In scrofulous 
children ostitis is mostly found in the short bones and in the 
epiphyses. The bones swell, become softened (porotic), in their 
interior suppuration loosens the tissue and dilates the medul- 
lary spaces so as to inflate and expand the thin external layer 
{spina ventosa). Tubercular ostitis softeus the bones into a yel- 
lowish caseous or fungous mass, and thereby forms cavities, 
which may heal by means of absorption of the liquid contents 
and calcification of the remnant, but mostly end in caries or 
necrosis, in fistulse, in persistent suppuration, and not rarely 
in amyloid degeneration. The degrees of the different forms 
vary considerably. For instance, necrosis may be superficial, 
with a favorable prognosis ; or central, with the formation of 
a sequestrum the removal of which incites granulations and 
new formation of bone; or total, and thus removes whole 
bones, such as the calcaneus, the cuboid, entire phalanges, or 
the diaphysis of a tibia. 

The prognosis is best when the process is superficial. Ab- 
solute rest, elevation of a limb, cold applications, tincture of 
iodine, occasionally leeches, and deep incision in case of very 
severe pain which betrays small quantities of pus comprise the 
proper treatment of an acute periostitis. Chronic thickening 
will usually be reduced, perhaps even removed, by moderate 
pressure, iodide of potassium internally, and (or) an ointment 
of the same with lanolin. Syphilitic periostitis requires iodide 
of potassium in increasing doses, occasionally combined with 
mercury. Ostitis and osteomyelitis (deep, agonizing pain, with 
but little swelling at first) require a treatment similar to that 
of periostitis. The bone should be kept at rest, well elevated 
and supported by splints, and ice applied. In mild and slow 
cases tincture of iodine, or the ignipuncture of Kocher, will 
yield favorable results. Syphilis demands its specific treat- 



470 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

ment. Incision may strike an abscess, which is then drained. 
Sequestrum is removed, and will be replaced by bone as long 
as there is no dangerous general affection. Antiseptic irri- 
gations are indicated in most of these cases, and antiseptic 
applications should be made constantly if gauzes are not used 
to fill a cavity or fistula. When caseous degeneration has 
taken place to a great extent, the question of mere scraping or 
of resection presents itself. Osteomyelitis requires an early 
operation, sometimes within a few days after the appearance 
of the first symptoms. Esmarch's bandage, the chisel, and 
the sharp spoon are the main reliances of the surgeon ; the 
seat of the disease must be reached and entirely uncovered ; 
counter-opeuings and ample tamponing may be demanded. 
Spina ventosa should be treated in a similar manner ; part of 
the remaining external osseous layer should be removed and 
the cavity filled with iodoform or other antiseptic gauze. 

In every case of this kind — in fact, every case of subacute 
or chronic inflamation of the osseous tissue — phosphorus 
ought to be given. It may be continued in such doses as are 
recommended elsewhere (p. 102) for two or three months in 
succession. 

Inflammations of the joints are frequent, — more so in infancy 
than in childhood. Acute cases are rare, however, in children 
eight or ten years old, who have more control of their muscles 
and take better care of themselves. Younger children are 
more exposed to traumatic injuries ; besides, not to speak of 
the phlebitis of the newly-born, there are in the earlier years 
distinct predisposing causes of joint-disease in such infectious 
diseases as scarlatina and diphtheria. The synovial membrane, 
the fibrous capsule, and the cartilage are affected either sep- 
arately or collectively, and the contents of the diseased cavity 
are either serous, or purulent, or fungous. Most of the latter 
are tubercular, and were known to be so long before the 
tubercular bacillus was discovered. Indeed, as early as 







DISEASES OF THE BONES AND JOINTS. 471 

1873, Koster recognized the tubercular nature of " tumor 
albus." 

The prognosis is fair when the secretion is serous. Fluctu- 
ation is easily recognized when the joint is superficial. It 
remains as " hydrarthros" in chronic cases. The treatment 
requires absolute rest, and in the acute 'stage the flexed position 
of the limb — which is either voluntarily chosen because it re- 
lieves tension, or is the result of a reflex contraction — must 
be respected. Other aids are : cold applications, rarely a local 
depletion, mustard plasters ; in less urgent cases, tincture of 
iodine, pure or diluted with alcohol, once or twice daily ; in 
chronic cases, a vesicatory either to its full effect of applied 
for half an hour only, and repeated daily or several times a 
day ; later, ointments of iodide of potassium and lanolin, 
or mercurial plaster, which may be made to cover the whole 
joint and may be changed once every few days ; two daily ap- 
plications of iodoform in collodion (1 : 8-20) over the whole 
joint ; and moderate compression. Iodide of potassium inter- 
nally will render good service while the affection is of a purely 
inflammatory character. Persistent contracture must be over- 
come by massage, passive movements, and forcible extension, 
either without or with anaesthesia. 

Tubercular cases have a decided tendency towards either 
suppuration or fungous degeneration. About the knee the 
abscess is often outside the capsule and permits of an incision 
which does not reach the interior. Intra capsular abscesses, the 
opening of which was once so dangerous as to be considered 
semi-criminal, are no longer the bugbear of surgery. Antiseptic 
irrigations and tamponing and draining have reduced the dan- 
gers and are daily swelling the records of recoveries. General 
treatment to overcome the anaemic and cachectic condition, 
and particularly antituberculous hygiene and medication, are 
demanded in most cases. 

Lately {Deutsche Zeitsch. f. Chirurgie, vol. xli., July 30, 



472 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

1895, p. 378), E. Wieland published a contribution to the 
treatment of surgical tuberculosis in childhood with iodoform 
injections which, to my mind, contains everything now known 
on the subject and all that is sound and advisable. Iodoform 
treatment is certainly not a panacea. Cases of tubercular 
coxitis, for instance, complicated with large abscesses and with 
perforation of the acetabulum, which offer great difficulties 
in the way of irrigation, of thorough cleaning out, of injec- 
tions, and of compression, are liable to resist iodoform treat- 
ment as well as to yield unfavorable results after a radical 
operative interference. But in a large percentage of cases in- 
jections of iodoform emulsions, aided by orthopaedic measures 
(bandages, stays, plaster of Paris) or by mild operative pro- 
cedures, and last, but by no means least, by constant atten- 
tion to the general health (air, food, clothing, and bathing), 
and by medicinal support with arsenic, creosote, or, pref- 
erably, guaiacol, yield good results. It is true, this treatment 
takes patience and time, is even apt to be expensive, and 
certainly exhibits no tangible proof of a great surgical achieve- 
ment to the impressionable lay mind ; but it is efficient, and 
has the advantage of not interfering with the growth and de- 
velopment of the limbs, which are mostly injured, and perma- 
nently so, by subjecting the epiphyses and the periepiphyseal 
cartilages to a radical operation. In not a few cases the absorp- 
tion of iodoform, when employed in solutions, has proved 
dangerous through a consequent toxic nephritis. For this 
reason, solutions in ether or oil are not to be recommended ; 
for, after all, it is the local effect of iodoform which is aimed 
at, and not a general one. Emulsions are preferable. Krause 
employs a suspension of ten per cent, of iodoform in water, 
with the addition of but little glycerin and gum-arabic. 

The places to be selected for injections, according to him, 
are, — for the wrist-joint, below the styloid process of the 
ulna; for the elbow, above the capitulum radii; for the 



DISEASES OF THE BONES AND JOINTS. 473 

shoulder, exteriorly from the coracoid process; for the hip, 
above the trochanter major ; for the knee, below the patella ; 
for the ankle-joint, below the malleolus, in an upward direc- 
tion. Periarticular abscesses should be incised and scraped 
thoroughly before an injection is made. The same holds 
good for fungous degeneration of the capsule of a joint. 
Bones in a very diseased condition — the talus, for instance — 
should be removed entire. If pus cannot be removed thor- 
oughly, counter-openings are required. At first, for the pur- 
pose of thorough cleansing and disinfection, injections may 
be made with a mild solution of bichloride of mercury 
(1 : 5000), to be followed for a few moments by a stronger 
one (1 : 1000-2000). The principle of conservatism must 
never be lost sight of. All are unanimous at present that 
conservative treatment is the more urgently demanded the 
younger the patient. Radical operations are indicated only 
when the case is one of extensive and protracted irremediable 
suppuration with progressive destruction of tissue. Resection, 
however, must not go beyond the cartilage between epiphy- 
sis and diaphysis. If tuberculosis be markedly developed, 
either locally or generally, it is better to amputate than to re- 
sect. Fistulse which do not contract or shorten should be 
treated with strips of gauze dipped in equal parts of balsam 
of Peru and alcohol, and when they are very dry and indolent, 
with (Yillate's) injections composed of sulphate of copper 10 
parts, sulphate of zinc 10 parts, and distilled water 120 parts. 
It is particularly the knee- and elbow-joints that require con- 
servative treatment, both cautiously and patiently. 

Another method of conservative treatment of tubercular 
joints has been introduced by A. Bier (Arch. f. Klin. Chir., 
1894, p. 306). Encouraged by the fact that lungs in a 
condition of passive hyperemia resulting from cardiac disease 
or from kyphosis have a rather pronounced immunity from 
tuberculosis, he advises to produce a passive venous congestion 



474 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

of the tubercular joints by bandaging the limb tightly below 
the affected joint and compressing it above with an india- 
rubber band (Esmarch). To secure a moderate amount of 
hyperemia and cyanosis, and to avoid undue pressure and 
oedema, the bandaging should be interrupted once or twice a 
day. Such a degree of passive hyperemia is known to give rise 
to the new formation of connective tissue and to induration. 
This, it is suggested, affords a certain degree of protection 
against the proliferation and action of bacilli. At least this 
is the effect aimed at by Landerer when he recommends cin- 
namic acid, and by Lannelongue, who injects chloride of 
zinc for that purpose. That such was Koch's theory when he 
introduced tuberculin is well known. 

Bier continues his treatment at least three months. Mas- 
sage, formerly used simultaneously, he has discarded. He 
found his method particularly practical when employed for 
tuberculosis about the ankle-, knee-, and elbow-joints, also for 
the testis, less so for the shoulder, not at all as yet for the 
hip-joint. He found, however, that if there were much sup- 
puration, the limbs thus obstructed now and then tended 
to acute inflammation, lymphangitis, or erysipelas. Ulcera- 
tions increased in size, but finally healed ; sometimes large 
granulations sprang up, but recovery eventually took place. 
Tubercular sequestra were often absorbed, and sometimes 
firmly attached to and embedded in the surrounding osseous 
tissue. Even tubercular skin was benefited by frequent dry 
cupping, but not to such an extent as joints and bones by 
the above treatment. Glands were not accessible to the same 
method, except the cubital. Sarcoma and lupus were rather 
the worse for it ; so was extensive suppuration with strepto- 
and staphylococci. 

The treatment, however, is not to be confined to this 
method alone. Abscesses are aspirated, if possible, in their 
upper part to avoid persistent discharge, and filled with 



DISEASES OF THE BONES AND JOINTS. 475 

a ten-per-cent. iodoform emulsion. Slight compression may 
follow, and the injection is repeated in about a week. If there 
be considerable purulent discharge, the iodoform treatment is 
continued or Villate's solution (p. 473) employed. Under its 
use bone fistulse heal rapidly. If loose splinters be accessible, 
they are removed. Forcible extension by apparatuses under 
anaesthesia, tenotomy, and plaster of Paris should be employed 
in the treatment when indicated ; so should passive movement, 
massage, and warm baths, particularly where there is func- 
tional anchylosis. True anchylosis requires resection when 
the false position of the extremity becomes intolerable, for a 
considerable curvature of the lower extremity or the extension 
or hyperextension of the upper cannot be borne. That gener- 
ous diet and proper hygiene and antiscrofulous and antituber- 
cular medication must not be omitted in an ailment which 
either is the result or may be the beginning of a generalized 
infection is self-evident. 

So far as the antitubercular treatment with guaiacol is con- 
cerned, I can but repeat what I said on the subject some time ago 
(International Medical Magazine, November, 1892, and Trans- 
actions of the American Climatological Association, 1892). 
No one treatment of all forms of tuberculosis ever satisfied 
me to the same degree as has that with guaiacol. In the 
different varieties of pulmonary tuberculosis, when the de- 
structive process was not too acute, it has almost invariably 
improved both appetite and general condition, rendered expec- 
toration less purulent, and increased the weight of the body 
as well as improved the complexion. The more chronic the 
cases the more perceptible is the effect of guaiacol. Thus, in 
tuberculosis of the osseous system its action is very satisfac- 
tory. The dose for a small child is from a drop to two drops, 
to be repeated three or four times a day. If the taste be ob- 
jectionable, the carbonate of guaiacol (an almost tasteless 
powder) may be substituted in three or four daily doses of 



476 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

from one to three or four grains each. Both of these prepa- 
rations, particularly the latter, may be combined with other 
drugs, according to indications, — preferably with arsenic in 
generalized tuberculosis of the soft tissues, with phosphorus 
in extensive inflammations of the bones of a chronic or sub- 
acute nature. 

Coxitis begins mostly in the head of the femur, and is rarely 
attended with very acute symptoms. As it is curable when 
recognized early, every case of dragging, of untimely fatigue, 
of favoring either limb, of vague pain, and of slight increase 
of body temperature in the afternoon requires careful and 
repeated examination. Pain in the knee depending on irri- 
tation of the obturatorius and internal saphenus nerves is 
not increased by pressure. Limping and apparent length- 
ening of the limb with abduction and shortening with adduc- 
tion are found not to be actual, but the result of voluntary 
change of position. These conditions are overcome by rest, 
the local applications mentioned above, and conscientious ex- 
tension in bed. At a later period, when all the symptoms 
of acute irritation have disappeared, counter-extension and 
extension by apparatuses may be employed for the purpose of 
permitting active exercise. When, however, the swelling in- 
creases, an abscess is formed, and perforation takes place, a 
spontaneous luxation will be the result, with either elongation 
or shortening (luxation upward and backward with adduction 
and inward rotation of the extremity). The os ilium may 
perforate, or what is left of the head of the femur may start 
for the sciatic foramen, or upward, and all of the head may 
be lost by suppuration. Even in these bad cases partial re- 
covery sometimes takes place. A new joint may be formed or 
actual anchylosis result from the healing surfaces joining each 
other. The size of the incisions will depend on that of the 
abscesses, and the operations on the bones on their condition. 
Complete resections ought to be made in as few instances as 



DISEASES OF THE BONES AND JOINTS. 477 

possible ; the peri epiphyseal cartilage controlling the growth 
of the limb requires careful protection. 

Tubercular coxitis is eminently a disease of early age. 
Nearly fifty per cent, of the cases occur during the first 
decade of life, nearly forty during the second. One-third of 
all the cases remain free of suppuration ; of these, seventy- 
seven per cent, get well j of the purulent form only forty-two. 
Altogether, about forty per cent, terminate fatally, death en- 
suing from tuberculosis of the lungs or of the meninges, or 
from general miliary tuberculosis, amyloid degeneration, or 
exhaustion by suppuration or by sepsis. About fifty -five 
per cent, get well under conservative treatment; still, the 
motility of the hip-joint is impaired by contraction, so that 
either adduction (in two- thirds of the cases) or abduction, with 
actual or apparent shortening of the extremity, results there- 
from. Actual shortening depends either on retarded growth 
or (in the process of bone destruction) on displacement of the 
acetabulum, which is more frequent than spontaneous luxa- 
tion ; apparent shortening on the voluntary elevation of the 
hip. 

The general rules of constitutional and local treatment hold 
good for gonitis (inflammation of the knee-joint), which is 
liable to be tubercular in perhaps a larger percentage than any 
other joint. Deformity becomes very marked at an early date, 
the leg is very apt to be luxated backward, and both pseudo- 
anchylosis (adhesion of the ends of the bones by connective 
tissue) and true anchylosis (solid connection of the cartilages 
or of the bones) are frequent. 

Inflammations of the ankle- and tarsal-joints are mostly 
tubercular. They take a slow course in most instances, and 
result but rarely in recovery unattended by deformity. Un- 
fortunately, constitutional tuberculosis is a frequent complica- 
tion, and death is not uncommon before even a local restitution 
can take place. The elbow-joint exhibits the same tendency to 



478 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

deformity and anchylosis, but is rarely the source of a hectic 
condition and of death. Early fixation in a sling and the 
application of either water-glass or plaster-of-Paris bandages 
are indispensable, while the forearm and the humerus should 
be placed nearly rectangularly. The same position must be 
secured for the foot. In coxitis and gonitis the limb ought to 
be kept entirely or nearly straight. 

Tuberculosis of the body of a vertebra (more frequent than 
that of the arch or of a process) underlies spondylitis in almost 
every case. The intervertebral cartilages are but secondarily 
affected. In many cases a trauma is charged with being the 
proximate cause, in others the process develops spontaneously, 
with but few symptoms. Stiffness on moving, pain on moving 
and pressure, very little, if any, increase of temperature, inabil- 
ity to bend and rise without support on a knee or some near 
solid object, are quite often the persistent, but only, symptoms. 
When spondylitis is cervical, it is liable to produce headache, 
dyspnoea, and retro-pharyngeal abscess ; when lumbar, pain in 
the thigh or symptoms resembling those of coxitis. Usually 
there is already pus either in the bone or at some distance from 
it. It finds its way along the fascia, rarely into the vertebral 
canal, and is met with in the gluteal region, in the small pelvis, 
along the psoas and internal iliac muscles, and along the rec- 
tum. There is rarely a recovery without some deformity. 
Cases with much suppuration exhibit lasting and marked 
kyphosis or scoliosis, or kypho-scoliosis. As soon as the diag- 
nosis can be made, the patient must remain on his mattress, with 
a moderate amount of extension. Ice will relieve local pain. 
When it is moderate, tincture of iodine will answer. Hueber 
recommended the subcutaneous injection of a two-per-cent. so- 
lution of carbolic acid. When there is no fever, the time for a 
plaster-of-Paris jacket, according to Sayre, has arrived. What 
the latter requires, however, is that the child should not be too 
young. To be useful, a certain length of the spine is necessary 



DISEASES OF THE BONES AND JOINTS. 479 

for its application. Thus, it is principally in the dorsal 
spondylitis of children of a certain age that it exhibits its best 
results. The jury-mast is added to support the head and 
thereby to reduce local pressure in cervical cases. Abscesses 
gravitating downward are better not touched before they reach 
the surface. Then, or after their spontaneous perforation, an- 
tiseptic irrigations and the use of iodoform emulsions are 
indicated. 

Genu valgum (knock-knee) is the exaggeration of a normal 
disposition produced by a slight depression of the external parts 
of the articular surface, mainly of the thigh. This disposition 
is increased by the rhachitical softening of the bone (in later 
life to an eminent degree by the pressure brought about by 
the occupation of bakers, waiters, saleswomen, etc.). The 
speedy cure of rhachitis is an essential preventive. A plaster- 
of- Paris support (which ought to be renewed every few weeks), 
made to dry while the extremity is gently flexed, procures 
a normal position while the bone is hardening under the in- 
fluence of phosphorus, etc. The elastic length-garters, which 
have to a great extent taken the place of the circular ones, 
applied below or above the knee, must not be tense, for in that 
case they increase the external concavity. They ought to be 
worn on the inside of the thighs, or both inside and outside. 
In bad and chronic cases osteotomy is performed above the 
condyle of the femur, also on the diaphysis of the tibia, and 
the bones are then allowed to heal in extension. Genu varum 
is almost always the result of a rhachitical outward curva- 
ture of (and below) the epiphysis of the tibia. It is but 
rarely that the femur participates in the deformity. If 
it be noticed in time, straightening can be effected before 
the parts harden. After this has taken place, osteotomy or 
osteoclasy must be resorted to. 

Pes varus (club-foot) is often congenital. Defective supina- 
tion is normal in the foetus, and becomes exaggerated by the 



480 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

pressure of the uterus when amniotic liquor is scanty. Iu 
many cases there is at birth a deformity of the talus of such a 
character that its neck is long externally and the head turned 
inward ; also of the calcaneus, whose anterior process is raised 
and articulations somewhat dislodged. According to H. von 
Meyer, the posterior tibial muscle is always primarily affected. 
The paralytic variety of club-foot results from immobility of 
the extremity, caused by-complete paralysis or by some other 
sickness necessitating protracted rest in bed, or from paralysis 
of the extensor muscles of the lower extremities consequent 
on poliomyelitis. The deformity is rather an equino-varus 
than a mere varus. 

As the articulations begin to suffer at a very early period, 
.and growth is very rapid, treatment should begin at once. 
Indeed, the foot which at birth is seventy-five millimetres in 
length, is one hundred and seven millimetres after a year, 
122.3 millimetres after two years, and 136.4 millimetres after 
three years. There is an increase of forty-three per cent, in 
the course of the first year ; this increase is the more rapid the 
younger the infant. After three months the foot has added 
one-seventh part to its original length, and another ninth in 
the second quarter. Therefore, recovery from a moderate de- 
gree of club-foot, when treatment begins at birth, will take 
three months ; when after a year, twelve months. 

Manual correction must be resorted to many times during 
the day. At night the tender foot of the newly-born bears 
quite well a pasteboard splint, well lined, and strapped with a 
snug bandage. Later, or in procrastinated cases, a plaster-of- 
Paris bandage or one of water-glass will be required to pre- 
serve the normal position. As there is occasional anaesthesia 
of the surface, great care must be taken lest undue pressure be 
exercised. After the above treatment has had a satisfactory 
effect, Scarpa's, Stromeyer's, Say re's, or any other shoe which 
permits of walking should be used. Tenotomy is required in 



DISEASES OF THE BONES AND JOINTS. 481 

a great many cases, — either of the tendo Achillis, or the an- 
terior tibial, or the plantar aponeurosis, or several of them at 
the same time. The open operation of A. M. Phelps has 
gained many friends. He cuts all the layers of the soft parts 
at the sole of the foot successively, avoiding the ramifications 
of the plantar nerve, and occasionally incising the articula- 
tions of the talus and of the navicular and internal cuneiform 
bones. The paralytic muscles require persistent use of both 
the interrupted and the continuous currents. The function 
of the muscles can be improved, provided the patience both 
of the physician and of the patient is equal to the necessity 
of the case. 

Pes equinus is the result of paralysis, either local, or spinal, 
or cerebral, and is complicated with atrophy of the muscles 
of the calf and of the sole of the foot, the sole becoming con- 
cave and the toes pointing downward. Here also tenotomy 
of the tendo Achillis and of the plantar aponeurosis, together 
with the employment of electricity and galvanism, are in- 
dicated. An apparatus is required to lift the anterior part of 
the foot, and while the patient is lying down or sitting up, he 
may practise upon a band properly attached to temporarily 
restore the normal position. Children will easily learn to 
look upon the exercise as play. 

Pes calcaneus in a mild form is often congenital and some- 
times complicated with pes valgus. The desirable position is 
restored by a shoe supplied with a high heel and so con- 
structed as to press the foot down. But lately operative 
surgery appears to have accomplished some of its greatest 
triumphs. 

Nicoladoni, to heal a talipes calcaneus with paralysis of the 
muscles of the calves, severed the peroneal muscles behind the 
malleolus and the tendo Achillis above the heel, and joined 
the central ends of the peroneal tendons to the stump of the 
tendo Achillis. Pocas, in a case of paralytic pes valgus, 

31 



482 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

connected the tendons of the extensor hallucis longus and of 
the paralyzed anterior tibial. Ghillini, to supplant the action 
of the paralyzed anterior tibial muscle, cut the tendon of the 
peroneus longus near the cuboid bone, also that of the anterior 
tibial six centimetres above its insertion, and joined both 
subcutaneously, with satisfactory result. 

Pes valgus (flat-foot) is not infrequently congenital, the 
talus being found downward and forward. In other cases 
the deformity is rhachitical. Both to prevent and to cure 
it, antirhachitical treatment and temporary rest are demanded. 
There are also (rare) paralytic cases occasioned by paralysis 
of the supinator muscles of the foot. In these electrical treat- 
ment and the subcutaneous use of strychnia, together with 
massage and stimulating embrocations and friction with cold 
or hot water, will render service. In all cases walking should 
not be permitted until a reasonable time has elapsed; the 
lower extremity should be raised, symptoms of vascular irri- 
tation relieved by applications of cold water, a normal po- 
sition enforced by plaster-of-Paris bandaging, which must 
be continued through weeks and months, and when walking 
appears to be again permissible, the inner margin of the foot 
must be raised by thickening part of the sole of the shoe, or 
by elevating it by springs which are elastic enough not to 
injure by pressure. 

From a practical point of view, the subdivision of scoliosis 
into three varieties is as follows : the first degree comprises 
those cases in which suspension of the body removes the de- 
formity altogether ; the second, those in which this effect is 
but partially attained ; the third, such as are riot influenced 
by it. The prognosis in the first is favorable ; in the second 
it is fair when the growth of the skeleton is not completed ; 
in the third it is not good, but should not be considered ab- 
solutely bad. It greatly depends on whether the scoliosis 
results from a relative or an absolute insufficiency of muscles, 



DISEASES OF THE BONES AND JOINTS. 483 

or whether it is caused by a deformity of the vertebral bodies. 
The latter may be congenital, but is frequently the result of 
rhachitical softening. In such instances a thorough anti- 
rhachitical treatment, with proper food and hygiene and phos- 
phorus, must not be postponed a single day. The habitual 
scoliosis of the first eight or ten years is of muscular origin, 
and mostly total and universal; the convexity generally to 
the left, or sometimes lumbar. This condition is found in 
babies who are persistently carried on the left arm ; in school- 
children who rest the left arm on the table while the body is 
accommodating itself to the book and leans to the right ; in 
girls who approach the bench sideways and pick up their 
skirts under the right gluteal region. The danger of be- 
coming scoliotic is particularly great in those school-chil- 
dren whose sight is defective. Those who stand a great 
deal and carry the right shoulder forward develop a right 
dorsal with a compensatory left lumbar scoliosis. The pre- 
vention of all varieties consists in the avoidance of their causes. 
A baby must not be persistently carried on one arm : a mother 
is more apt to obey this rule than a nurse. The muscles must 
be exercised at an early age, — simple domestic gymnastics, but 
not overexertion ; and the habitual use of cool or cold washing 
once or twice a day, with good food and air and plenty of sleep 
on a hair mattress, are indispensable. The school sessions 
ought not to be longer than forty or forty-five minutes ; there 
must not be too many of them ; there should be ample light 
from the left side while the child is studying or writing ; de- 
fective sight must be corrected by glasses ; the chairs or benches 
supplied with a support up to the lower dorsal region of the 
spine. During school sessions a light corset may also be worn, 
and at night an apparatus to restore the equality of the two 
sides. Massage of the defective side and of the muscles in 
general will add to the good effect, and the concave side of the 
chest may be exercised by the enforcement of the habit of 



484 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

deep inspiration while the hand is firmly planted and pressed 
on the convexity. Dr. Teschner's successes are due to the 
systematic exercise and strengthening of all the muscles of the 
body. 

In more obstinate cases the foot corresponding with the 
lowered hip may be raised by thickening the sole of the shoe. 
Volkmann recommended the raising of the chair or bench 
under the dropping hip. Sayre's corset is either worn con- 
stantly or is made to be detached. Rauchfuss's apparatus is 
so constructed as to leave the defective side but little or not at 
all supported while the patient is lying down. 

The kyphosis of feeble rhachitical children requires general 
antirhachitical treatment. The baby must not sit up until 
the muscles have become stronger ; the bed should have a hair 
mattress ; and the patient must take the air while being car- 
ried either on a hair mattress or in a wire cuirass, or in a tin 
or pasteboard or sole-leather mould sufficiently lined to be 
comfortable. As the baby grows, walking must not be en- 
couraged. He will rise when his bones are hard enough and 
his muscles sufficiently strong. 



ADDENDA. 485 

XVI. 

ADDENDA. 

Valuable additions to pediatrics have been made within 
a short time. Laborde's method of treating asphyxia of the 
newly-born consists in rhythmical traction of the tongue, 
which is caught in a forceps and drawn out at regular inter- 
vals twenty times a minute. The same method has been em- 
ployed in the apncea of anaesthesia. Pernicious ansemia has^ 
been treated by Fraser with bone-marrow. In one of his 
cases, in which, though iron, arsenic, and salol had been given 
previously, the number of blood-cells in a cubic centimetre 
was reduced to one million and haemoglobin to twenty-five 
per cent., speedy improvement took place. Small doses, either 
raw or broiled, ought to be given in the beginning, for the 
taste is not acceptable to the patient. Methylene blue is rap- 
idly coming into favor in the treatment of carcinoma. I 
never saw a case cured by it, but very many improved and re- 
tarded. The daily dose for a young child ought not, at first, 
to exceed three or four centigrammes (gr. J-f ). In sarcoma 
the toxin of the erysipelas bacillus combined with that of the 
bacillus prodigiosus, according to Coley, appears to be bene- 
ficial. In carcinoma it seems to be useless. 

Infantile scurvy ("Barlow's disease") has become very ame- 
nable to treatment, both in its early and in its advanced stages. 
Its main and characteristic symptoms are pain in the (mostly 
lower) extremities, swelling (mainly) of the diaphyses depend- 
ing on subperiosteal hemorrhages, petechia? and ecchymoses 
of the skin, particularly of the eyelids, spongy condition and 
purple color of the gums, and sometimes separation of an 
epiphysis. These symptoms are frequently complicated with 
the tumefied epiphyses and other marks of rhachitis. The 



486 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

prognosis is good. The principal remedy is fruit juice, — 
from one-half to two oranges a day, or a pineapple, is the 
specific. Complications with rhachitis require, besides, the 
elixir of phosphorus. Sterilized milk, if the only nutriment, 
as in many instances it will be found to have been, must be 
combined with cereal decoctions, and meat broths should be 
added as a regular food. 

Since the almost uniform efficacy of thyroid gland in myx- 
edema and its partial effect in cretinism became established 
facts, many more experiments have been made with the sub- 
stances or extracts of other animal glands; for instance, in 
tetany and exophthalmic goitre. But in neither of these have 
the results been such as to permit the establishing of proper 
indications for its use. It is not improbable, however, that 
the next few years will greatly add to our knowledge of the 
action of animal substances, particularly glands. Macalister 
has employed thymus gland in pseudo-hypertrophy, and 
Mikulicz in goitre and Graves's disease ; in the latter it has 
also been used by Owen and Cunningham. The action of 
some of the glands may be excretory only. When they are 
removed or diseased, their secretion is believed to accumulate 
in the body and thereby give rise to autoinfection. Others 
may constantly contribute a secretion which is required for the 
normal life of the tissues, which exhibit a toxic effect through 
its absence. This, at least, is the theory advanced by Schaefer 
and Oliver in reference to the supra-renal capsules.* 

Not quite so efficacious as thyroid in myxcedema, but still 
more beneficial in its general usefulness because of the vast 
number of cases in which it is applicable, is the antitoxin 
of diphtheria. Though its claims are not yet recognized by 
all, and not equally estimated by its friends, its general results 
are no longer questionable. Nor is there a practitioner but has 

* British Medical Journal, August 10, 1895. 



ADDENDA. 487 

at present the right — or, rather, the duty — to give it a place 
among his most reliable remedies. If present experience is 
confirmed by many more similar facts, it will be entitled to 
be claimed as a specific, though it have not the power to 
cure every case of diphtheria any more than qui ma cures 
every case of malaria or mercury of syphilis. Not countiug 
isolated cases spread over the journals, the three hundred of 
Heubner's, five hundred of Baginsky's, thousand of Roux's, 
and the many hundreds of the hospitals of Paris and Vienna, 
besides those of our own country, yield a basis on which to 
establish calculations. All observers agree on this point, that 
the sooner the antitoxin is injected the more certain is its effect. 
Some go so far as to assert that no case injected the first day 
need die. 

The doses to be administered are, according to Behring, as 
follows : according to the severity of a case, six hundred, one 
thousand, or fifteen hundred " antitoxin units" should be in- 
jected in a part of the body which contains loose subcutane- 
ous tissue and is not exposed to pressure. This dose may 
be repeated if the symptoms are not improved within a day. 
A " unit" is equivalent to one cubic centimetre of what is 
called "normal serum." Normal serum is the blood-serum 
of an immunized animal, which has been made so efficacious 
that one-tenth of a cubic centimetre will antagonize ten times 
the minimum of diphtheria virus fatal to a guinea-pig weigh- 
ing three hundred grammes (ten ounces). 

It appears to be a fact acknowledged by all that there is 
rarely, if ever, an immediate bad result of the injection. 
Not infrequently, however, there is redness, erythema, or urti- 
caria around the point of injection. Besides, some of the 
after-effects are liable to be very severe. Urticaria, polymor- 
phous eruptions, petechia? and suggillations, excessive perspira- 
tion, swelling of glands, severe pain and swelling in feet and 
limbs and joints, pruritus recti, severe diarrhoea and vomiting, 



488 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

nose-bleeding, and great debility have lasted for weeks, yet 
terminated in recovery. A few deaths have also been reported, 
but the cause was doubtful, it appears, in every case. 

Dr. James Ewing * studied the effect of antitoxin on the 
number and nature of leucocytes. While leucocytosis begins 
a few hours after the invasion of diphtheria, and increases up 
to the climax of the disease and steadily declines during 
convalescence, — remaining high only in most of the bad and 
fatal cases, — antitoxin, according to Ewing, within thirty 
minutes after its injection, causes a reduction of the number 
of leucocytes. This reduction affects specially the uninuclear 
leucocytes, while the proportion of well-stained multinuclear 
cells is increased. In favorable cases, after the injection of an- 
titoxin the leucocytosis never again reaches its original height. 
In severe and less favorable cases the injection is followed in 
a few hours by more hyperleucocytosis and fever. In very 
bad cases the immediate result may be either rapid increase or 
decrease of leucocytes, and death. The multinuclear leuco- 
cytes found in the blood of favorable cases after treatment 
with antitoxin show increased affinity for gentian violet. This 
change may be observed within twelve hours after the injec- 
tion, and its non-occurrence is a very unfavorable prognostic 
sign. 

The existence of the after-effects mentioned above is not 
denied by any of the most enthusiastic admirers of antitoxin, 
but it is claimed that no serious or lasting results follow, 
and that if every life threatened by diphtheria were known 
to be protected by enduring the untoward effects of the 
remedy, we should willingly submit to them in every case. 
The balance of what we know of antitoxin is thus far favor- 
able, and this addition to our therapeutical powers will forever 
be remembered as creditable to Emil Behring. The lack of 

* New York Medical Journal, August 17, 1895. 



ADDENDA. 489 

recognition, which was some time ago withheld from him by 
many, was, most unfortunately, his own fault. The morbid 
vanity and some personal motives displayed in almost every 
one of his writings tallied so badly with the tendencies and 
spirit of a scientific benefactor as to render suspicious both his 
veracity and his motives. It is, therefore, a pleasure to notice 
the circumspection and moderation of his latest elaborate paper 
on the same subject.* • 

Altogether, the effects of antitoxin injections are very favor- 
able. The fever of diphtheria is much lessened within or 
after a day, and the second fever- wave — so common between 
the third and the fifth days — is said not to appear. The 
membrane is speedily disintegrated and disappears on the 
sixth day or sooner, while in cases not injected with antitoxin 
it lasts eight days or longer. Besides, there are but few cases 
on record in which the membrane returned after antitoxin, and 
not many in which it grew in size. In 181 cases of Heubner's 
there were but three relapses. Albuminuria and nephritis are 
common occurrences in diphtheria as early as the (second and) 
third day. Among these 181 cases of Heubner's, of those in- 
jected on the first day, five-sixths remained free ; on the second, 
two-thirds ; on the third, one-half; on the fourth, one-third. 
The results of Baginsky, Roux, and Widerhofer are similar. 
In 525 cases of Baginsky 's treated with antitoxin there was 
albuminuria in 40.95 per cent., clinical nephritis in 12.57 per 
cent., and nephritis (post-mortem) in 15.80 per cent. How- 
ever, among 933 cases treated without antitoxin there was 
albuminuria in 42 per cent., clinical nephritis in 25.78 per 
cent., and post-mortem nephritis in 16.31 per cent., — rather a 
favorable showing for antitoxin. In his 525 cases, heart- 
failure was noticed as the cause of death in eight ; it occurred 



* Kesults and Aims of Serum Therapy, Deutsche Med. Wochenschr. 
September 19, 1895. 



490 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

in 5.69 per cent, of all the cases, while it took place in 10.9 
per cent, of the 933 treated without serum, from 1891 to 1894. 
In Heubner's practice it occurred nine times, but was not 
fatal. 

It is claimed that whenever antitoxin is injected before 
laryngeal stenosis has developed, the larynx will remain free. 
Thus both tracheotomies and intubations have become less in 
number. Pn Baginsky's hospital service there were, between 
the years 1890 and 1894, 1258 cases of diphtheria ; 418 trache- 
otomies and 135 intubations were performed, with a total 
mortality in these 553 operations of 62 per cent. In the 418 
tracheotomies the mortality was 64.4 per cent. ; among these 
were 77 which were performed after intubation ; these 77 had 
a mortality of 69 per cent. ; 58 intubations without secondary 
tracheotomy had a mortality of 41.8 per cent. This condition 
of things changed with the period of antitoxin treatment. No 
case of laryngeal stenosis developed in those in whom the 
remedy had been injected before the larynx became afYected. 
Thus, in 525 cases there were but 53 tracheotomies and 54 
intubations, the former with 34 deaths, the latter with 2. 
It became necessary to perform tracheotomy after a previous 
intubation in 12 cases; of these, 9 died. The speedier disin. 
tegration of the membranes and the (almost general) discon- 
tinuance of their growth after the injection of antitoxin are 
the reasons why Baginsky prefers at the present time, in the 
injected cases, intubation to tracheotomy. 

Other observers arrive at similar results. Heubner had 33 
operations in 181 cases, — viz., 23 tracheotomies with 52 per 
cent., 10 intubations with 80 per cent, recoveries. 

Paralysis is no less frequent in antitoxin cases than it was 
formerly. But we must not lose sight of the fact that it never 
was exclusively found in very bad cases, but quite often after 
mild ones. Perhaps it results more from a mild but pro- 
tracted poisoning than from a sudden and severe one. It may 



ADDENDA. 491 

be, also, that many cases which survive with antitoxin and 
develop paralysis would not have lived to become paralyzed 
under a less satisfactory treatment. 

The principal question, however, to be raised in reference 
to any medication in cases of serious disease is its life-saving 
power. In its issue of August 8, 1895, the Deutsche Medi- 
cinische Wochenschrift published a preliminary result of its 
collective investigation of antitoxin treatment. The report 
refers to 10,312 cases of diphtheria treated in the city of Berlin 
and outside : total mortality, 11.8 per cent. Of that number, 
4479 were treated without antitoxin and 5833 with it. Of all 
the patients, 1233 were below two years, with a mortality of 
29 per cent. ; 6740 from two to ten years, with a mortality of 
11.4 per cent.; 2339 over ten years, with a mortality of 3.9 
per cent. 

Of the 4479 treated without antitoxin (mortality 14.7 per 
cent.), 498 were below two years, with a mortality of 39.7 
per cent.; 2710 from two to ten years, with a mortality of 
15 per cent. ; 1271 over ten years, with a mortality of 3.7 
per cent. 

Of the 5833 treated with antitoxin, 735 were below two 
years, with a mortality of 21.8 per cent. ; 4030 from two to 
ten years, with a mortality of 8.8 per cent. ; 1068 over ten 
years, with a mortality of 4.1 per cent. 

On the first and second days antitoxin was injected in 401 
cases of less than two years, with a mortality of 11.8 per 
cent. ; 2256 cases of from two to ten years, with a mortality of 
4 per cent. ; 696 cases of over ten years, with a mortality 
of 1 per cent. ; total, 3353 cases, with an average mortality 
of 4.2 per cent. 

On the third day and later antitoxin was injected in 334 
cases of less than two years, with a mortality of 34.4 per 
cent. ; 1774 cases of from two to ten years, with a mortality 
of 14.9 per cent. ; 372 cases of over ten years, with a mor- 



492 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

tality of 9.9 per cent. ; total, 2480 cases, with an average 
mortality of 16.9 per cent. 

Among the antitoxin cases there were 1018 of diphtheritic 
croup, of which 701 were treated without tracheotomy, with 
a mortality of 17.9 per cent. ; 317 with tracheotomy, with a 
mortality of 33.1 per cent. These figures show, undoubtedly, 
that only the very urgent and most severe cases were subjected 
to the operation. Of all the cases of laryngeal stenosis, there 
were, below two years, without tracheotomy, 130, with a 
mortality of 29.3 per cent. ; below two years, with tracheot- 
omy, 49, with a mortality of 49 per cent. ; from two to ten 
years, without tracheotomy, 484, with a mortality of 15.9 per 
cent. ; from two to ten years, with tracheotomy, 250, with a 
mortality of 30 per cent. ; over ten years, without tracheotomy, 
87, with a mortality of 12.7 per cent. ; over ten years, witn 
tracheotomy, 18, with a mortality of 38.8 per cent. 

Not the least interesting statements refer to the quantities 
of antitoxin employed. In 3497 cases, 600 antitoxin units, 
or less, were used in 497 cases under two years, with a mor- 
tality of 16.1 per cent. ; 2370 cases from two to ten years, with 
a mortality of 5.3 per cent. ; 630 cases over ten years, with a 
mortality of 1.8 per cent. ; the average mortality being 6 per 
cent. 

In 2336 cases, up to 1000 antitoxin units were used, of 
which 238 cases were under two years, with a mortality of 
33.6 percent. ; 1660 cases were from two to ten years, with a 
mortality of 13.8 per cent. ; 438 cases were over ten years, 
with a mortality of 7.5 per cent. ; the average mortality being 
14.6 per cent. 

These figures show that the milder cases, in which 600 units 
were considered enough, did best ; that those which from the 
beginning offered a worse prognosis were given more antitoxin 
and did not behave so well. 

Among the most enthusiastic eulogizers of antitoxin there is 



ADDENDA. 493 

none but admits failures. Many of these are attributed to an 
insufficient strength of the serum. Mere serum of an immune 
animal does not suffice. Others — and these are the most con- 
clusive — depend on the insufficient power of resistance on the 
part of the patient. Thus the antitoxin injection alone should 
not be relied on. Nutrition and alcoholic and other medicinal 
stimulation, such as I have detailed in another part of this 
book (p. 189), must be resorted to. In regard to other treat- 
ment the authorities differ. Some, like Escherich, Baginsky, 
and Roux, favor it, Escherich particularly after the membranes 
have fallen off. Heubner rejects it. At all events, there are 
but few left who maltreat both the throat and the child by the 
former cruel methods of local applications and cauterizations. 
I have advised, whenever I had an opportunity, the combina- 
tion of my mercurial treatment with the antitoxin, for the 
reports on the efficacy of mercurial treatment as recommended 
by me (p. 201) are becoming more and more favorable. Ben- 
ney ? s Australian results and reports are very conclusive.* 
Some New York friends, to whom I offered antitoxin, declined 
it, declaring themselves fully satisfied with the results they 
obtained from mercury and intubation. On the other hand, a 
towns-fellow of ours who handles antitoxin a good deal pro- 
nounces mercury and antitoxin to be incompatible, and believes 
that mercury will interfere with the effect of antitoxin. This 
assertion has not been proved, but shows the facility with 
which postulates may be substituted for experience during a 
period of enthusiasm. 

So far as immunization through small doses of antitoxin 
is concerned, it appears to have been accomplished, in the 
opinion of many ; but they all agree that it does not last long. 
Those who know that diphtheria, once induced, predisposes 
rather than protects will have no particular confidence in the 

* Australian Medical Journal, January 20, 1895. 



494 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

effect of antitoxin as an immuuizer ; but if it saves the lives 
of many who are stricken, its sphere of usefulness will be 
indeed extensive. 

It is evident that great and successful strides have been 
made in medical therapeutics. Improvements take place 
partly through the aid of pharmaceutical preparations and 
of the products of biological research, partly through new 
methods and appliances for hygienic and preventive purposes. 
It is mainly the infectious diseases which have been served 
by the former, and both public and individual hygiene by the 
latter. Early life has been particularly benefited, and by 
nothing more than by careful endeavors to improve the diet 
of the young, and thereby to remove the dangers of intestinal 
disorders and the sources of excessive mortality. Nothing has 
been more successful in that direction than the wide-spread 
practice of sterilization and pasteurization of cow's milk. 
Both are the logical development of the plan of treating milk 
by boiling which I have persistently advised these thirty-five 
years at least, and detailed in my " Infant Diet," in Ger- 
hardt's " Handbuch," in Buck's " Hygiene," in " Intestinal 
Diseases of Infancy and Childhood,"* and in my clinical lect- 
ures delivered during the last third of a century. There can 
hardly be a doubt that if raw milk could always be had 
unadulterated, fresh, and untainted, it would require no boil- 
ing. It would even contraindicate it, for high temperatures 
destroy at once the bacteria whose action is desirable for nor- 
mal digestion. But such ideal milk cannot be had so long as 

* P. 18. " After boiling, milk destined for the use of a baby during the 
day should be kept in clean bottles containing from three to six ounces, 
filled up to the cork, and the bottles then turned upside down in a cold 
place ; such will keep longer than milk preserved in the usual way. Be- 
fore being used it should be heated in a water-bath ; and by repeating this 
heating of the whole amount of the day's milk several times during the 
twenty-four hours, fermentation will be retarded and digestibility im- 
proved. ' ' 



ADDENDA. 495 

cows are tuberculous, scarlet fever and diphtheria are met with 
in the houses aud about the clothing and on the hands of dairy 
men and women, and typhoid stools are mixed with the water 
which is used for washing utensils. 

Now, what is it that boiling can and will do? Besides 
expelling air, it destroys the germs of typhoid fever, Asiatic 
cholera, diphtheria, and tuberculosis, also the oidium lactis, 
which is the cause of the change of milk-sugar into lactic acid 
and of the rapid acidulation of milk with its bad effects on 
the secretion of the intestinal tract. Some varieties of pro- 
teus and most of bacterium coli are also rendered innocuous 
by boiling. Thus it prevents many cases of infant diarrhoea 
and vomiting, but not all of them, for the most dangerous 
bacteria are influenced neither by plain boiling nor by the 
common methods of sterilization. Besides, " diarrhoea'' is but 
a symptom of many causes, and " cholera infantum" is a name 
for a condition occasioned by many. Ebstein emphasizes the 
fact that babies at the breast are subject to cholera infantum, 
particularly in southern climates, also in public institutions. 
The influence of external temperature is a very important 
factor ; its sudden changes produce intestinal disorders. Babies 
taken from a hot railroad car to the deck of a lake steamer, 
from a warm bed to a draughty room, may develop a ca- 
tarrhal enteritis which disposes to worse forms of disease, for 
the morbid condition of the epithelium caused by such sudden 
changes is a proximate cause of disease because it opens the 
way to all sorts of infecting substances. Poisons in the food 
of cows, indigestible baby foods, — either indigestible per se or 
through a morbid condition of the digestive organs, — produce 
diarrhoea of many varieties. It need not even depend on in- 
gested food, for, according to W. Schild's recent investigations 
(Zeitseh. f. Hyg. u. Infect, xix.), germs of diseases may be 
found in the intestine of the newly-born in from ten to seven- 
teen hours after birth (minimum four, maximum twenty). 



496 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

The meconium of the newly-born being free of germs, is sup- 
plied through the mouth with the bacterium coli, and through 
the anus with the bacillus fluorescens, subtilis, and proteus. 
Even adults are infected through the same inlet. Linen, the 
bath, the air, the blood, are sources of local invasion. In 
such cases what is the sterilization of artificial food to accom- 
plish ? They are not reached by it. 

Not even the natural food, breast- milk, is free of germs 
possibly attended by dangers. M. Cohn and H. Neumann 
found germs in the healthy breast-milk, even after the mamma 
and nipples had been washed with alcohol and with solutions 
of corrosive sublimate. A. Palleske met with the staphylococ- 
cus pyogenes albus in one half of all healthy womeu, F. Honig- 
mann (Zeitsch. f. Hyg. u. Infect, xiv.) in most of them, and 
H. Knochenstein (Inaug. Diss., 1893) in the mammae of eight 
puerperal and nursing women. Evidently they had immigrated 
from outside ; they proved innocuous. But who can doubt 
that if the epithelium of the milk-ducts had been morbid, 
there would have been a chance for mastitis, or if the staphy- 
lococcic milk had come in contact with a sore stomach or in- 
testine, there would have been an opportunity for gastritis or 
enteritis ? 

Nor is boiling, or sterilization, a safe protection under all 
circumstances. Aerobic bacteria, the so-called hay or potato 
bacilli, with very resistant spores, which are found in cow- 
dung and in the dust of stables, of the soil and streets, and 
of hay, peptonize casein and liquefy it and render the milk 
bitter. They are very poisonous ; their pure culture gives 
young dogs a fatal diarrhoea. It takes hours of sterilization 
to kill them ; in some instances it required five or six hours. 
Even the bacillus butyricus takes an hour and a half. But 
such a protracted sterilization, besides being far from certain 
in its effect, is a clumsy procedure and one not calculated to 
benefit the milk. Thus, hay feeding is an absolute necessity, 



_ 



ADDENDA. 497 

for the bacilli are destroyed by a six weeks' drying. Besides, 
it is important to keep the stables scrupulously clean, to avoid 
dirt and dust, to employ peat instead of straw for bedding, 
to wash the udder and tie the tails before milking, to throw 
away the first milk, and to remove foreign material from the 
milk by centrifuging. But no absolute security can be guaran- 
teed. Therefore, Fliigge adds to his expositions a warning 
against some wholesale manufacturers who, always anxious 
about somebody's — their own — welfare, were (are ?) known to 
conceal the changed condition of the milk and the separation 
of butter particles by coloring the glass of their bottles. 

Whatever I have here brought forward is certainly not to 
disparage the boiling of the milk ; it is meant to prove the 
danger of relying on a single preventive when the causes of 
intestinal disorders are so many. It is true, however, that 
the large majority of the latter depend on causes which may 
be met by sterilization, but not by sterilization only ; also by 
pasteurization, — that is, heating the milk to 70° C. = 165° F., 
and keeping it at that temperature for thirty minutes, — a pro- 
cedure which destroys the same germs that are killed by a 
more elevated temperature without much change in the flavor 
and taste of the milk. 

One of the questions connected with the employment of 
sterilized or pasteurized milk is this, whether the milk to be 
used for a child ought to be prepared at home, or whether the 
supply may be procured from an establishment where large 
quantities of milk believed to become immutable for an indefi- 
nite period by sterilization are kept for sale. In regard to 
this problem, Fliigge plaintively expresses his regrets that " we 
have allowed ourselves to be guided by people who are neither 
hygienists nor physicians, but chemists, farmers, or apothecaries, 
and whose actions have been based on three false beliefs. Of 
these the first is that boiling for three-quarters of an hour 
destroys germs, the second that whatever bacteria remain un- 

32 



498 THEEAPEUTICS OF INFANCY AND CHILDHOOD. 

destroyed are innocuous, and the third that proliferating bac- 
teria can always be recognized by symptoms of decomposition." 
Nothing is more erroneous. Soxhlet himself, the German 
originator of sterilization, knew at an early period that the fer- 
menting process is now and then but partially interrupted by 
boiling, that butyric acid may be found in place of lactic acid, 
that a strong evolution of gas may be caused after such boiling, 
and that such milk may give rise to flatulency. Aye, milk 
which happens to contain the resistant spores of bacteria be- 
comes a better breeding-ground for them by the very elimina- 
tion of lactic acid, and the longer such sterilized milk is pre- 
served and offered for sale the worse is its condition. It may 
be true that these conditions are not met with very frequently, 
but an occasional single death in a family caused by poisonous 
milk will be more than enough. Therefore, the daily home 
sterilization is by far preferable to the risky purchase from 
wholesale manufacturers who cannot guarantee because in the 
nature of things they cannot know the condition of their 
wares. 

Another alteration of a less dangerous character, but far 
from being desirable, is the separation of cream from sterilized 
milk which is preserved for sale. Renk (Arch. f. Hyg. y xvii.) 
found that it took place to a slight extent during the first 
weeks, but later to such a degree that 43.5 per cent, of all the 
cream contained in the milk was eliminated. 

Sterilization has been claimed to be no unmixed boon be- 
cause of its changing the chemical constitution of milk. Still, 
opinions on that subject vary to a great extent, the occur- 
rence of changes being both asserted and denied by apparently 
competent judges. But what I have said a hundred times is 
still true and borne out by facts ; — viz., that no matter how 
beneficial boiling, or sterilization, or pasteurization may be, it 
cannot transform cow's milk into woman's milk, and that it is 
a mistake to believe that the former, by mere sterilization, is a 



— 



ADDENDA. 499 

full substitute for the latter. It is true that when we cannot 
have woman's milk we cannot do without cow's milk. There 
is no alleged substitute that can be had with equal facility or 
in sufficient quantity. But after all it is not woman's milk. 
Babies may not succumb from using it, and may but seldom 
appear to suffer from it ; indeed, they will mostly appear to 
thrive on it ; but it is a makeshift after all and requires modi- 
fications. Hammarsten was the first to prove the chemical 
difference between the casein of cow's and woman's milk. 
Whatever was known on this subject at that time I collated 
in Gerhardt's a Handb. d. Kind.," vol. i., 1875 (2d ed., 1882). 
But lately Wroblewski demonstrated the difference in solu- 
bility of the two milks. Woman's casein retains, during pepsin 
digestion, its nuclei n (proteid rich in phosphorus) in solution : 
it is fully digested ; in cow's casein the nuclein is not fully 
digested : a " paranuclein" is deposited undissolved and un- 
digested. Besides, woman's casein contains an additional 
albuminoid which is not identical with either the known 
casein or albumen. (H. Koplik in N. F. Med. Journal, April 
13, 1895.) 

Ergo, cow's milk is not woman's milk. It is not identical 
with it. Sterilization does not change its character ; it merely 
obviates such dangers as result from the presence of patho- 
genic germs and from premature acidulation. The substitu- 
tion of cow's milk or of sterilized cow's milk for woman's 
milk as the exclusive infant food is a mistake. Experience 
teaches that digestive disorders, such as constipation or diar- 
rhoea, and constitutional derangements, such as rhachitis, are 
frequently produced by its persistent use, and it appears to 
be more than an occasional (at least co-operative) cause of 
scurvy. 

Since the advisability of finely dividing and suspending the 
casein of cow's milk and of adding to the nutritiousness of 
the latter caused me always to teach the admixture of cereals 



500 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

to it, even in the very first days of infancy, the subject of 
infant feeding has never been lost sight of by medical men, 
scientists, and tradesmen. No subject has been treated more 
extensively, more eagerly, sometimes even more spitefully, 
than that of infant feeding. The philosopher's stone has 
not been so anxiously sought for nor so often found in medi- 
cal journals, books, and societies as the correct infant food 
and the appropriate treatment of cow's milk. After the 
finally faultless thing had been discovered very many times, 
it was not a surprise but a source of gratification to me to 
meet, in the Berl. Klin. Woch., No. 10, 1895, an article of 
Heubner's, who, after having contributed for years as much 
as any writer (if not more) to the literature of the subject, rec- 
ommends the " utilization of flour in the intestines of young 
nurslings." Basing his remarks, first, on the researches of 
Schiffer, Korowin, and Zweifel (quoted in my early writings 
on that topic more than twenty years ago), who, by experi- 
mentally proving the digestibility of a certain amount of 
starch in the saliva (and pancreatic juice) of young infants,* 
justified my empirical findings of many previous years, and, 
secondly, on what he is pleased to call " Jacobi's practical ex- 
perience," the Berlin physician recommends in intestinal dis- 
eases of the very young the simplest flours, mainly of rice and 
oats (which have a finer microscopical structure than wheat). 
He pointedly adds, " Very young infants do better on a dilu- 
tion of milk with a thin rice decoction than with mere milk- 



* Bias dies hard. While it took Heubner more than twenty years to 
avail himself of very accessible physiological experience, a celebrity of 
equal rank (Philip Biedert, Handbuch der Kinderkrankheiten, 11th ed., 
1894, p. 39) still appears to approve of the opinion that a nursling must 
have " no amylacea" because of their indigestibility, before the protrusion 
of teeth. Before long it will be a generally accepted axiom that cereals 
must be given to make teeth when milk food alone does not suffice for 
their development. 



ADDENDA. 501 

sugar solution. Practical experience surpasses theoretical 
conclusions." * There is but one point in which the famous 
teacher does not yet agree with me, for in his expositions we 
meet with the remark that he " cannot approve of the colossal 
dilution recommended by the authority of Jacobi." The 
" colossal dilution" alluded to is that of milk in four or five 
parts of oatmeal- or barley-water for the use of the newly- 
born. In regard to this dilution also I trust I shall yet see 
my illustrious colleague siding with me. The demands of 
pepsin digestion and of rapid growth and the necessity of 
restitution of losses experienced by eliminations and excre- 
tions are just so many reasons for extra allowances of water 
in the diet of very young infants, who have to rely on the 
services of others. Older children know how to find it and 
how to serve themselves. In addition, it is certainly true 
that a large amount of water passiug through the kidneys 
removes the inconveniences and dangers of the peculiar physi- 
ological process which takes place during the first three weeks 
of every life, — viz., uric acid infarctus, — the results of which 
are gravel, renal calculus (by no means rare), and nephritis. 
Indeed, since the rather frequent adoption of my plan 
of supplying the very young with quantities of water, I hear 
less of renal complaints in them than I did dozens of years 
ago. 

Perhaps the tide is already beginning to turn in my direc- 
tion. Norbert Auerbach, whose researches on the difficulty 
of destroying the hay bacillus and the bacillus butyricus are 
very meritorious, recommends larger percentages of water in 
infant feeding than the customary ones. His mixtures for 
the first and second months of life are three parts of water 
and one of milk ; for the third and fourth, two and one ; for the 
fifth and sixth, one and one ; for the seventh and eighth, one 

* " Probiren geht iiber Studiren." 



502 THEEAPEUTICS OF INFANCY AND CHILDHOOD. 

and two. His figures are, therefore, not exactly like mine, 
but even they may appear heretic to my critic. In connection 
with this subject I am also pleased to state that Auerbach 
agrees with me on another subject. The sugar he adds to the 
milk food of infants is not milk-sugar, but cane-sugar, of 
which he gives twenty grammes daily, and — also according to 
my old teaching — more during constipation. He undoubtedly 
prefers cane-sugar for the reasons which guided me in my 
recommendations, though it is true that milk-sugar is being 
stripped of its dangers in the same degree as boiling, steriliza- 
tion, or pasteurization is carefully practised. 

Virtually, sterilization has been practised by me these more 
than forty years, and has been taught by me for thirty-five 
years, both in lectures and in books and essays. My method 
has been referred to. I always urged that safety increased 
with the number of boilings. Still, certain New York gen- 
tlemen have been pleased to say, even lately, and one of 
them has printed, though he was told of his mistake before 
printing, that Jacobi was an opponent of sterilization. 

Actual sterilization, according to Soxhlet, was introduced in 
New York by A. Caille. Then manufacturing firms took it 
up as a matter of course. One of them was prevailed upon 
by me to execute a device of Dr. A. Seibert, who advised the 
determination of the amount of sterilized food and the grad- 
uation of the feeding-bottles according to the weight of the 
infant. In most cases this plan is good, for the condition of 
the child can mostly be measured by the increase of its weight. 
Only fat, clumsy, rhachitical children are exceptions ; in them 
the rapid increase of weight is rather a morbid condition 
than a symptom of healthy development. Besides, he im- 
proved his food by adding, in conformity with my practice, 
and sterilizing at the same time with the milk, either barley-* 
or oatmeal-water. A recommendation of his sterilizer is its 
cheapness, which makes it more accessible to the poor. His 



ADDENDA. 503 

plan, — developed later, — to filter milk before sterilization, is 
identical with that recommended by Auerbach. 

The writings and practical instruction of Dr. Rowland 
Godfrey Freeman have been a great advantage to New York, 
particularly to its poor population. He insists upon pasteur- 
ization as a sufficient method of safety. As the adviser of 
Mr. Nathan Strauss in his successful endeavors to supply 
thousands with a safe article of food, he has benefited the city 
and aided in setting an example which should and will be 
imitated. 

Pasteurization is also employed by Rotch. In a paper read 
before the American Pediatric Society at Boston, May 4, 1892,* 
he presented, among others, the following statements, which I 
gladly repeat, as I know his teachings to have done a great 
deal of good. Indeed, I was so much impressed by them 
that I encouraged the gentleman who had conducted a milk 
laboratory on Dr. Rotch's plan in Boston to establish a similar 
institution in New York. Some of Dr. Rotch's statements 
are as follows : 

"What the profession needs is the knowledge that they 
may have milk laboratories where the materials are clean, 
sterile, and exact in their percentages. Slight changes in the 
three elements of milk of which we have the most accu- 
rate knowledge — namely, fat, sugar, and albuminoids — are of 
real practical value in managing the digestion and nutrition 
of the infant (normal percentage of fat, 2.02-4.37 ; of milk- 
sugar, 5.70-7.10; of albuminoids, 1.08-3.07; of mineral 
matter, 0.12-0.20). The digestive capabilities of infants dif- 
fer just as do those of adults, and nature therefore provides 
a variety of good breast-milks adapted to the individual idio- 

* The Value of Milk Laboratories for the Advancement of our Knowl- 
edge of Artificial Feeding, by T. M. Eotch, Archives of Pediatrics, Feb- 
ruary, 1893. Also Pediatrics, the Hygienic and Medical Treatment of 
Children, Philadelphia, 1896, pp. 153-287. 



504 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

syncrasy of the special infant. With this fact impressed 
upon us, we can well see that in artificial feeding no routine 
mixture will in all cases prove successful.* We are in need 

*A11 this proves also that nature allows a great deal of latitude, for 
the milk of a woman is changing, sometimes quite rapidly, and still the 
baby continues to thrive. It also proves that an attempt at regulating 
the percentages of milk according to invariable rules, while circumstances 
of surroundings and individual health — perceptibly changed or not — may 
differ, is liable to be very deceptive. Altogether, no iron-clad rule holds 
good for a living body in which organic assimilation is not regulated by 
the fixed laws of crystallization. This is, indeed, proved by nothing better 
than by the variability of the constituents of good milk. According to 
the very figures presented by Dr. Rotch himself, fat may vary from 2.02 
to 4.37, albuminoids from 1.08 to 3.27, and still the milks exhibiting these 
wide differences are " normal." 

In regard to the percentages of fat in cow's and in woman's milk, the 
results of chemical analysis have lately changed in favor of the latter. 
But the general principles in regard to fat feeding — its effect on digestion, 
and the normal occurrence of fat in the healthy faeces of an infant fed on 
normal nourishment (breast-milk) — are not thereby altered. 

Neither mathematics nor chemistry alone directs the organic economy. 
If that were so, the chemist Soxhlet, otherwise so deserving and justly 
famous, would be justified in the advice he coolly gives the physician to 
add milk-sugar when there is no fat in the food, and thereby to obtain the 
necessary amount of carbon hydrates. Fortunately, organic chemistry is 
not identical with physiology. 

The methods of Biedert and Arthur Meigs are based upon these modern 
analyses of milk. The former prepares a cream mixture which contains 
one per cent, of casein, two of fat, and four of sugar. It is to be mixed 
with milk in different proportions. One of the reasons urged by him for the 
addition of cream is the greater dilution (accomplished by my cereal decoc- 
tions) of the cow casein, the difficult digestion of which he takes for granted. 
The mixture of Dr. Meigs is well thought of by many physicians ; but it 
is too easily influenced by irregularities and by accidents happening to the 
cream while being obtained and to the milk-sugar solution to be proof 
against frequent failures and to become popular among the masses. — 
(Jacobi's Intestinal Diseases, p. 32.) 

Dr. N. B. Coit, who acts on the assertion that cow's milk, when prop- 
erly prepared, furnishes a whole and sufficient diet for an infant and sup- 
plies all its needs for robust health, gives the following rules for " modified 
milk for infant feeding, made with one quart of bottled cow's milk : first 



ADDENDA. 505 

of a means by which we can prescribe exactly according to 
the idiosyncrasy of the digestion we are dealing with. 

" A separator with many thousands of revolutions in a min- 
ute separates from the milk foreign material and divides it 
up into a cream of a stable percentage and separated milk. 
The milk-sugar and the albuminoids, also the mineral matter 
of this milk, are fairly well known, and thus the laboratory 
worker is enabled to put up any prescription, which, for a 
healthy baby of four months, would read : fat, 4 parts ; milk- 
sugar, 7 parts ; albuminoids, 1.50 parts. Put up eight tubes, 
each four ounces, with lime-water ten per cent. Pasteurize 
(75° C. = 167° F.) for twenty minutes. In this mixture 
the lime-water is just sufficient to slightly alkalinize the 
cow's milk.* In this way the food of the child can be 

six months, the top milk, cream one-half pint, boiled water one pint, 
milk-sugar seven hundred grains; from six to nine months, the top milk, 
cream one pint, boiled water one pint, milk-sugar nine hundred grains ; 
from nine months to one year, the top milk, cream one and one-half 
pints, boiled water one-half pint, white sugar three teaspoonfuls. " 

* Cow's milk is either alkaline, or neutral, or acid. The constant rec- 
ommendation of five per cent, of lime-water for the purpose of alkalization 
is, therefore, far from exact and strictly scientific. Besides, how much 
alkalization is effected by one and a half drachms of lime-water ? They 
contain exactly, or are presumed to contain, one-eighth of a grain of lime. 

Lime-water (liquor calcis) is a saturated aqueous solution of calcium 
hydrate whose percentage varies with its temperature. At 59° F. it con- 
tains somewhat over 0.17 per cent., in rising temperature less, at the boil- 
ing-point one part of lime in thirteen hundred of water. It redissolves as 
the liquid cools. If the food containing lime-water be given at a tempera- 
ture of eighty or ninety degrees, part of the lime is thrown out. Lime- 
water warmed loses most of its alkaline reaction ; it is markedly alkaline 
when cold, only faintly so when boiled. An experiment made with good 
milk from the household supply gave the following results : Eeaction 
acid, also on boiling. One-twentieth part of lime-water added to it changed 
the reaction but slightly ; it remained acid. The mixture being boiled, 
reaction remained the same. When again cooled and shaken up it was 
still acid, but slightly less so than before the dilution of the milk with 
lime-water. 



506 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

modified according to age and to changed conditions of 
health." 

In a case of duodenal jaundice in a girl of six years, the doc- 
tor prescribed fat, 0.5 part ; milk-sugar, 6 parts ; albumi- 
noids, 4 parts. Give four ounces every two hours. Send 
twelve tubes, each four ounces, lime-water ten per cent. In 
a case of summer diarrhoea in a girl of four months, fat, 2 
parts ; milk-sugar, 5 parts • albuminoids, 1 part. Send twenty 
tubes, each one ounce and one drachm. At time of each feed- 
ing add lime-water, three drachms. Sterilize at 212° F. 

One of the beliefs guiding the author of this method is as 
follows : " The constituents of the nutriment which nature has 
provided for the offspring of all animals and human beings that 
suckle their young are essentially animal, and not vegetable. 
Human beings in the first twelve months of life are carnivora. 
An animal food entirely and always free from any vegetable con- 
stituents has been proved to be the nutriment on which the great- 
est number of human beings live and the least number die." 

Those who have followed my teachings at any time during 
the last third of a century know that I take some exception 
to this broad statement. Saliva and pancreatic juice are good 
for something better than idle elimination, and " nature" pre- 
pared the animal young from the first moment for more than 
mere pepsin digestion. The proof Dr. Rotch refers to is 
his experience only. Mine has taught me somewhat differ- 
ently from the axiomatic positiveness of his assertion. But 
be it far from me not to present Dr. Rotch's case in full. 
His standing and merits are such as to give him a hearing 
wherever and whatever he discusses. His rules, which, more- 
over, .may be modified by my method at any time, are thor- 
oughly good ; they are scientific, exact, and well thought out. 
Moreover, they have been proved to be practicable. No mat- 
ter whether it is the careful handling of a cautiously prepared 
milk, the methodical composition according to percentages, or 



ADDENDA. 507 

the faithful pasteurization, or all of them, the results are good. 
I know of a number of babies who in health and disease have 
done well on the protracted use of the laboratory milk. Only 
one observation struck me in a few cases. The formation of 
the muscles, and particularly of the bones, appeared to be slow ; 
the teeth came a number of weeks or even months too late ; 
the cranial bones turned slightly soft in a few instances. In 
a few such cases I had to add animal broths or juice before 
the usual time; in one I tried phosphorus (elixir phosphori), 
which was rejected ; in others it was well borne and useful. 
But, taken all in all, the method appears to be sound and suc- 
cessful, so far as it can be with cow's milk and the casein of 
cow's milk. It is to be deplored that for the present it is a 
method only accessible to the rich ; mine has the advantage of 
being one for the people, both rich and poor. If, or as long 
as, the circulars of the laboratory keep free of pretentious 
exaggerations, — they have been taking that turn lately, — the 
profession will do well to rely on it, or its like, as one of the 
means of furnishing the baby a food deprived of dangers and 
in most cases sufficient. When found insufficient as regards 
tissue-building, cereals can always be furnished in the same 
mixture. The empirical knowledge of their beneficial effects 
with which we have been furnished for more than a generation 
has lately again been tested experimentally by Springer, of 
Paris, who improved the development of bone by a decoc- 
tion of mixed cereals boiled for hours in succession. This long 
duration of the boiling process is, however, not demanded. 

Like Professor Rotch, Professor G. Gaertner,* of Gratz, 
employs the centrifuge f for the purpose of obtaining a milk 

* TJber die Herstellung der Fettmilch, Wien, 1894. Professor Escherich, 
Die Gaertnersche Fettmilch, eine neue Methode der Sauglingsernahrung. 
Both in Wiener Med. Woch., 1894. 

f Eecommended for the preparation of children's milk in my Intestinal 
Diseases, 1887, p. 23. 



508 THERAPEUTICS OF INFANCY AND CHILDHOOD. 

resembling that of woman. The latter was found by Escherich 
to contain casein 1.82, fat 3.10 ; and sugar 6.23 per cent. The 
average of many examinations of cow's milk resulted in 
casein 1.76, fat 1.81, and sugar 2.4 per cent. That of "fat 
milk" contained casein 1.76, fat 3, and sugar 2.4 per cent. 
This " fat milk" is obtained by so arranging the tube which 
expels the cream from the centrifuge separator that just one- 
half of the milk contained therein is expelled and collected. 
In this way, as casein, sugar, and minerals are not affected 
by the process of centrifuging, the percentage of the latter 
is not changed, while that of the fat is doubled. The dif- 
ference between Gaertner's and Rotch's methods is this : that 
the former is applicable to the large majority (but that only) 
of infants who require cow's milk appropriately prepared ; 
and that the latter permits of all sorts of changes and percent- 
ages, and of all adaptations to the requirements of both the 
well and the sick, according to the opinions and intentions of 
the physician in every individual case. 



^■B 



INDEX. 



A. 

Abscesses, articular, 473, 474. 

periarticular, 473. 
Acne, 424. 
Alcohol, 23. 

indications for the use of, 23. 
Anaemia, arsenic in, 97. 

causes of, 91. 

cerebral, 383. 

iron in, 95. 

oxygen in, 97. 

pernicious, 484. 

prophylaxis of, 92. 

tendency to, 70. 

treatment of other organs in, 
95. 
Anchylosis, 475. 
Aneurism, congenital tendency to, 

371. 
Angioma, 53, 373. 
Animal food ip. anaemia, 93. 
Ankle-joint, 477. 
Antacids, 239. 
Antitoxin, 486. 

and mercury, 493. 

paralysis after, 490. 
Anus, fissure of the, 268. 

paralysis of the, 266. 
Asphyxia, causes of, 38. 

treatment of, 38. 
Asthma, 327. 
Atelectasis, 44, 326. 
Atheroma, 437. 



Athetosis, 407. 
Auerbach, N., 501. 

B. 

Bacillus butyricus, 496. 
Baginsky, 489, 490, 493. 
Balanitis, 303. 
Balano-posthitis, 303. 
Barlow's disease, 485. 
Baruch, S., 334. 
Bathing, 50. 
Baths, 89. 

Beef-tea dangerous in summer diar- 
rhoea, 21. 
Beneke, 369. 
Benney, 493. 

Biedert, 325, 370, 384, 504. 
Bier, 473. 
Bladder, irritable, 290. 

paralysis of the, 395. 
Blennorrhoea, 64. 
Blepharitis, 450. 
Blood of the young, 92. 
Blood-vessels, 371. 

congenital dilatation of, 373. 
Boiling of milk, 494. 
Bones, diseases of the, 464. 
Bourneville, 381. 

Brachial plexus, paralysis of the, 379. 
Brain, anaemia of the, 383. 

hernia of the, 390. 

hyperaemia of the, 382. 

tumors, 381. 
Bromides in epilepsy, 411. 

509 



510 



INDEX. 



Bronchial catarrh, 324. 
chronic, 325. 
Bronchitis, 324. 

fibrinous, 326. 
Broths, 21. 
Bulbar paralysis, 390. 
Buphthalmos, 459. 
Burns, 419. 

C. 

Caffeine, 363. 

contraindication to, 363. 
Caille, A., 230, 322, 387, 502. 
Calcaneus, pes, 481. 
Cane-sugar or milk-sugar ? 16. 
Caput obstipum, 462. 
Carbolic acid in infants, 58. 
Casein in faeces, 18. 
Catalepsy, 406. 
Cataract, congenital, 458. 
Catarrh, nasal, 309. 
Cereal admixture, 499. 
Cerebral diseases, diet in, 35. 

hyperemia, alcohol in, 364. 
Cerebro-spinal meningitis, 390. 

complication of, with pneu- 
monia, 392. 
prevention of, 392. 
Chalazion, 449. 
Chemosis, 453. 

Chest, deformities of the, 341. 
Chloroform, inhalation of, 83, 84. 
Cholera, 156. 
Chorea magna, 406. 

minor, 402. 
Choroid, 458. 
Circular dementia, 414. 
Circulation, diseases of the organs 

of, 355. 
Circumcision in poliomyelitis, 398. 
Club-foot, 479. 

after poliomyelitis, 398. 



Cohn, M., 496. 
Coit, N. B., 504. 
Coley, 485. 
Colic, 246. 
Coloboma, 448. 
Comedones, 425. 
Conjunctiva, 451. 
Conjunctivitis, 64, 451. 

chronic, 452. 

diphtheritic, 453. 

follicular, 454. 

gonorrhceal, 453. 

granular, 454. 
Consanguinity in mental disorders, 

415. 
Constipation, 241. 

apparent, 242. 

causes of, 242. 

and treatment of, 30. 
Contractures, 395. 
Convallaria, 362. 
Cough, periodic night, 328. 
Coxitis, 476. 

tubercular, 477. 
Craniotabes, 101. 
Craniotomy, 380. 
Cretinism, 414. 
Croup, intubation in, 320. 

mercurials in, 319. 

pseudo-membranes in, 318. 
Cryptorchis, 306. 
Curvatures, 464. 
Cyclitis, 458. 
Cyclopia, 448. 
Cystitis, 289. 
Cysts, 437. 

dermoid, 437, 448. 

sanguineous, 437. 



Deaf-mutism, 447. 
Delirium tremens, 414. 



INDEX. 



511 



Dementia, 413. 
Depletion, 89. 
Dermoid cysts, 437, 448. 
Diabetes, 137. 

insipidus, 139. 
Diarrhoea, 247. 

causes of, 248. 
Digestive organs, 227. 
Digitalin, 361. 
Digitalis, effect of, 362, 364. 
Diphtheria, 179, 486. 

bichloride of mercury in, 201. 

chlorate of potassium in, 188. 

disinfection, rules for, 183. 

heart-failure in, 189. 

local treatment in, 192. 

paralysis of, 203. 

prevention of, 179. 
Diphtheritic laryngitis, 318. 
Diuretin, 363. 

Doses depend on locality of admin- 
istration, 75. 

not always determined by age, 
74. 
Drinking-water, 421. 
Dysentery, 157. 
Dyspepsia, 24, 232. 

nervous, 238. 
Dystrophy, progressive juvenile 

muscular, 379. 
Dysuria, 290. 



Ear, diseases of the, 439. 

foreign bodies in the, 439. 

polypus in the, 442. 
Eclampsia, 400. 
Ecthyma, 427. 
Eczema, 427. 

papular, 427. 
Egg mixture, 22. 
Elbow-joint, 477. 



Electrical current, 377. 
Electricity, 86. 

in asphyxia, 42. 
Embolism, 383. 
Emphysema, 328. 
Empyema, 350. 
Encephalocele, 390. 
Endocarditis, 365. 

chronic, 368. 

muscular exercise in, 369. 
Enemata, 75. 
Enteritis, 29. 
Epicanthus, 448. 
Epilepsy, 407. 
Epileptic dementia, 414. 
Epistaxis, 314. 
Equinus, pes, 481. 
Erysipelas, 177, 423. 

alcohol in, 423. 

scarifications in, 423. 
Erythema, 420. 

nodosum, 214, 422. 
Erythromelalgia, 432. 
Escherich, 493. 
Ewing, 489. 

Excitement to be avoided, 72. 
Exomphalus, 65. 
Exophthalmic goitre, 405, 486. 
Exostoses, multiple, 467. 
Expectant treatment, 70. 
Extremities, malformations of the, 

464. 
Eye, diseases of the, 448. 

foreign bodies in the, 449. 

injuries of the, 450. 

malformations of the, 448. 

neoplasms of the, 448. 

F. 

Facial nerve, paralysis of the, 379. 
Earadic current, 377. 
Eat diarrhoea, 19. 



512 



INDEX. 



Favus, 433. 

Feeding of sick children, 9. 
Fever, causes of, and diet in, 33. 
from intestinal fermentations, 
33, 68. 
Fibromata, 437. 
Flat-foot, 482. 
Flechsig, 412. 
Fliigge, 497. 

Fomentations, warm, 89. 
Food, condensed, 232. 
Fractures, 468. 
Franklinism, 378. 
Freeman, K. G., 503. 
Frost-bite, 420. 
Funnel chest, 341. 
Fiirbringer, 387. 
Furunculosis, 426. 

G. 

Gaertner, G., 507. 
Galvanic current, 377. 
Galvanism over the spine, 394. 
Gangrene, symmetrical cutaneous, 

432. 
Gargles, 85. 
Gastric catarrh, acute, 26, 234. 

chronic, 27, 235. 
Gastritis, 26, 234. 
Genito-urinary organs, 280. 

pseudoplasms of, 307, 308. 
Genu valgum, 479. 

varum, 479. 
Gerster, 381. 
Ghillini, 482. 
Glands, bronchial, 342. 

mediastinal, 342. 
Glaucoma, 459. 
Glioma, 449. 
Glottis, paralysis of the, 321. 

spasm of the, 320. 



Goitre, 322. 

exophthalmic, 486. 
Gonitis, 477. 
Guaiacol, 385, 475. 
Gummata, 449. 



Hammarsten, 499. 
Heart, congenital anomalies of the, 
370. 
disease, bathing in, 359. 
diet in, 355. 
drugs in, 360, 
exercises in, 358. 
iodide of potassium in, 363. 
growth of the, 369. 
the skin in the diseases of the, 

358. 
undersize of the, 371. 
Heffen, 365. 
Hemeralopia, 457. 
Hemicrania, 379. 

Hemiplegia, infantile spastic, 390. 
Hemorrhage, pulmonary, 340. 

symmetrical cutaneous, 432. 
Hemorrhagic diathesis, 133. 
Hernia, inguinal, 67, 265. 

umbilical, 264. 
Herpes tonsurans, 434. 
Heubner, 489, 493, 500. 
Hip-joint, congenital luxation of 

the, 464. 
Hoffa, 465. 

Hoffmann, F. A., 231. 
Honigmann, F., 496. 
Hooping-cough (see Whooping- 
cough). 
Hun, 381, 382. 
Hydrocele, 308. 
Hydrocephalus, 387. 
injections in, 389. 
medication in, 389. 



INDEX. 



513 



Hydrocephalus, punctures in, 388. 
Hydrochloric acid, secretion of, 12. 

when required, 21. 
Hydropericardium, 370. 
Hydrophthalmos, 459. 
Hydrorrhachis, 398. 
Hydrothorax, 353. 
Hymen, imperforate, 305. 
Hyperemia of the brain, 383. 

I. 

Ice, 88. 

Ichthyosis, 437. 
Icterus, 61, 
Idiocy, 380, 414. 
Impetigo, 427. 

contagiosa, 433. 
Infant food, salt in, 229. 

water in, 229. 
Infarctus, pulmonary, 340. 
Influenza, 327. 
Inguinal hernia, 67, 265. 
Inhalation in pulmonary diseases, 
83. 

of medicines, 81. 
Intermittent fever, 141. 

treatment of, 141. 
Intertrigo, 423. 
Intestinal autoinfection, 422. 

catarrh, 29. 
Intussusception, 260. 
Invagination, 2G0. 
Iodide of potassium in myocarditis, 

365. 
Iodine, use of, 110. 
Iris, tubercles of the, 449. 
Iritis, 457. 

J. 

Jaundice, 61, 273. 
Joints, diseases of the, 464. 
inflammation of the, 470. 



K. 

Kephalbsematoma, 46. 
Keratitis, 454. 

diffuse, 456. 

neuro-paralytic, 456. 

parenchymatous, 456. 
Keratoconus, 457. 
Kidneys, 280. 

carcinoma of the, 281. 

echinococcus of the, 281. 

floating, 281. 

malformations of the, 281. 

sarcoma of the, 281. 
Knochenstein, H., 496. 
Knock-knee, 479. 
Koplik, 499. 
Korowin, 500. 



Laborde, 485. 
Landry's paralysis, 392. 
Lannelongue, 380. 
Laryngismus stridulus, 103. 
Laryngitis, acute, 316. 

chronic, 317. 
Larynx, acute catarrh of the, 316. 

enchondroma of the, 321. 

epithelioma of the, 321. 

fibroma of the, 321. 

neoplasms of the, 321. 

papilloma of the, 321. 
Leptomeningitis, spinal, 392. 
Lichen, 424, 425. 

acuminatus, 425. 

planus, 426. 

scrofulosorum, 425. 
Lime-water, 505. 
Lipoma, 436, 449, 
Liver, 270. 

cirrhosis of the, 272. 

congestion of the 272. 



33 



514 



INDEX. 



Liver, enlargement of the, 270. 

fatty infiltration of the, 271. 
Lorenz, 465. 
Lungs, hernia of the, 341. 

gangrene of the, 339, 341. 

pseudoplasms of the, 341. 
Lupus, 435. 

Luxation, congenital, of the hip- 
joint, 464. 
Lymph-bodies, 111. 



M. 

Macalister, 486. 
Mamma, 53. 
Mania, 413. 
Mastitis, 53. 
Mastoid process, 446. 
Masturbation, 294, 306. 
Measles, 171. 
Meigs, Arthur, 504. 
Melaena, 63. 
Melancholia, 413. 
Meltzer, 378. 
Meningitis, cerebral, 382. 

tubercular, 384. 
Meningocele, 390. 

spuria, 390. 
Mental disorders 413. 
causes of, 416. 
Mesenteric glands, 255. 
Methylene blue, 485. 
Meyer, H. von, 480. 
Microcephalus, 380. 
Microphthalmia, 448. 
Mikulicz, 486. 
Milk, how to preserve, 230, 

240. 
'. Mineral springs, 110. 
Molluscum contagiosum, 434. 
Monomania, 414. 



Moral insanity, 414. 

Mumps, 175. 

Muscles, diseases of the, 460. 

Muscular atrophy, 379. 

Myasthenia, pseudo-paralytic, 461. 

Myelitis, transverse, 392. 

Myocarditis, 357, 364. 

digitalis in, 365. 
Myositis, 460. 

chronic, 461. 

infectious, 460. 

ossifying, 460. 

rheumatic, 460. 

traumatic, 460. 
Myringitis, 441 , 443. 
Myxoedema, 414, 486. 

N. 
Naevus, 373. 

lipomatodes, 437. 

pigmentosum, 437. 

verrucosus, 437. 
Nares, treatment of the, 85. 
Nephritis, 282. 

chronic, 286. 

subacute, 285. 
Nervous system, diseases of the, 376 
Neumann, H., 496. 
Newly-born, treatment of the, 38. 
Nicoladoni, 481. 
Night-terrors, 417. 

O. 

(Edema, neuropathic, 432. 

pulmonary, 340. 
Oliver, 486. 
Omphalitis, 58. 
Opium in epilepsy, 412. 
Oral secretion, diastatic effect of, 11. 
Orbit, 459. 
Orchitis, 307. 



INDEX. 



515 



Osteochondritis, 468. 
Ostitis, 468. 

tubercular, 469. 
Otitis externa, 440. 

media, 443. 
Overstrain, 417. 
Overstudy, 382. 

P. 

Pachymeningitis, spinal, 392. 
Palleske, A., 496. 
Pancreas, diastatic effect of, 11. 
Papillomata, 431. 
Paralysis, Landry's, 392. 

muscular, 461. 

tropho-neurotic, 461. 
Paramyoclonus, 392. 
Paraphimosis, 303. 
Paratyphlitis, 259. 
Paresis, 414. 

Parotid gland, diastatic effect of, 11. 
Pavor nocturnus, 417. 
Peliosis, 213. 
Pemphigus, 430. 

exfoliativus, 431. 

foliaceus, 431. 
Pepsin requires much water, 13, 

229. 
Peptonized beef, 22. 
Pericarditis, 369. 
Perichondritis, 468. 
Perimastitis, 53. 
Periostitis, 468. 

albuminous, 469. 
Peritonitis, 275. 

tubercular, 257, 278. 
Perityphlitis, 257. 
Pernicious anaemia, 484. 
Pertussis, 216. 
Pes calcaneus, 481. 

equinus, 481. 



Pes valgus, 482. 

varus, 479. 
Phelps, A. M., 481. 
Phimosis, 298. 
Phosphates, 32. 
Phosphorus, 102. 
Pleurisy, 342. 

aspiration in, 352. 

dangers of operation in, 351. 

diagnosis difficult in, 347. 

explorative puncture in, 346, 
349. 

operation in, 345. 

radical operation in, 352. 

thoracocentesis in, 350. 

treatment of, 343. 
Pneumonia, 328. 

absolute rules in, 330. 

alcohol in, 334. 

antipyretics in, 331. 

cold applied in, 332. 

complication with malaria, 339. 
with nephritis, 339. 

cough in, 338. 

digitalis in, 335. 

gangrene in, 339. 

heart-failure in, 334. 

heart-stimulants in, 337. 

hypostatic, 339. 

interstitial, 329. 

lobular, 329. 

mustard baths in, 336. 

pleural pain in, 338. 

temperatures in, 330. 

treatment of interstitial, 339. 
Pneumothorax, 354. 
Poliomyelitis, 392. 

acute, 395. 
Polyneuritis, 379. 
Polypi, nasal, 313. 
Prepuce, 296. 

adhesions of the, 296. 



516 



INDEX. 



Prepuce, diphtheria of the, 301. 
Preventive treatment, 71. 
Prurigo, 424, 426. 
Pseudo-hypertrophy, 379. 

mercury in, 379. 
Psoriasis, 436. 
Psychical diseases, 413. 
Pupil, atresia of the, 448. 
Pyopneumothorax, 354. 



Q. 



Quincke, 387. 



Kabic virus in epilepsy, 412. 
Rectal alimentation, 36. 

feeding, 235. 

injections, 253. 
Rectum, polypus of the, 269. 
Kehn, 388. 
Renal calculi, 288. 

diseases, diet in, 36. 
Renk, 498. 
Respiratory diseases, diet in, 35. 

organs, 309. 
Retina, 459. 

glioma of the, 449. 
Rhachitis, 31, 98. 

cod-liver oil in, 99, 109. 

constipation in, 106. 

due to digestive diseases, 98 

malt in, 99. 

phosphates in, 102. 

respiration in, 104. 

treatment of bones in, 100. 
Rheumatism, 204. 

chronic articular, 467. 

diet in acute, 36. 

endocarditis in, 210. 

gonorrheal, 212. 

muscular, 215, 462. 
Rotch, T. M., 503. 



Roux, 489, 493. 
Rubella, 175. 
Rudisch, 234. 

mixture, 23. 
Rupia, 427. 



S. 

Sachs, 381. 

St. Vitus 's dance, 402. 

depending on nasal re- 
flex, 402. 
Salaam spasm, 413. 
Saliva in early infancy, 231. 

still active in the stomach, 12. 
Sarcoma, 485. 
Sayre, 478, 484. 
Scabies, 432. 
Scarlatina, 164. 
Schaefer, 486. 
Schiffer, 500. 
Schild, 495. 
Schools, 417. 
Scleroma, 49. 
Sclerosis, amyotrophic, 392. 

disseminated, 390. 

lateral, 392. 
Scoliosis, 482. 

Scrofula, phosphates in, 110. 
Scurvy, infantile, 485. 
Seborrhcea, 424. 
Seibert, A., 502. 
Sick children, feeding of, 9. 
Sinapism, 86. 
Skin, atrophy of the, 437. 

condition of the, 86, 88. 

congenital diseases of the, 436. 

diseases of the, 419. 

neoplasms of the, 436. 

neuropathic affections of the, 
431. 

tuberculosis of the, 436. 



INDEX. 



517 



Skull, operations on the, 380. 
Sodium chloride, 17. 
Soxhlet, 498. 
Sparteine, 362. 
Spasmus nutans, 413. 
Spina bifida, 398. 

ventosa, 469. 
Spinal canal, 392. 

tapping of the, 387. 

cord, treatment of the, 393. 
Spleen, diseases of the, 274. 
Spondylitis, 478. 
Stammering, 418. 
Starr, 381. 
Static current, 378. 
Sterilization, 71, 494. 
Sterno-cleido-mastoid muscle, hem- 
atoma of the, 48. 
Stomach, dilatation of the, 236. 

ulceration of the, 238. 
Strabismus, 459. 
Strophanthus, 362. 
Strophulus, 425. 

Strychnia subcutaneously, 395, 397. 
Subcutaneous injections, 79. 
Submaxillary gland, diastatic effect 

of, 11. 
Substitutes for breast-milk, 20, 503. 
Sugar, addition of, to milk, 15. 
Supernumerary fingers and toes, 464. 
Suppositories, 78, 
Synechia of the fingers, 464. 
Syphilis, 129. 

calomel in, 132. 

inunctions in, 132. 

iodides in, 134. 
Syphilitic baby, nursing of a, 129. 

T. 

Tabes, 392. 

suspension in, 395. 
Tarsal-joint, 477. 



Telangiectasia, 373. 
Teschner, 484. 
Tetanus, 63, 399. 
Tetany, 404, 486. 
Thrombosis, 372, 383. 
Thymus, 323. 
Thyroid gland, 322. 

medication, 414. 

in psoriasis, 415. 
in scleroderma, 415. 
Toes, congenital enlargements of 

the, 464. 
Tongue not pathognomonic, 11. 
Torticollis, 462. 
Trachoma, 453. 
Trismus, 63. 
Troltzsch, 446. 
Tubercular meningitis, 384. 
j Tuberculosis, 113. 

arsenic in, 121. 

causes of, 114. 

climato- therapy in, 118. 

digitalis in, 122. 

guaiacol in, 475. 

hemorrhage in, 127. 

hygiene of, 120. 

night-sweats in, 128. 

of the intestines, 126. 

of the larynx, 125. 

of the pharynx, 126. 

of the skin, 436. 

of the tongue, 126. 

preventive treatment of, 114. 

surgical, 472. 

treatment of, 118. 
Tumors, abdominal, 257. 

of the brain, 381. 
Typhoid fever, 143. 

brain in, 152. 
calomel in, 145. 
complications of, 146. 
constipation in, 150. 



518 



INDEX. 



Typhoid fever, convalescence from, 

155. 
diarrhoea in, 149. 
diet in, 84. 
expectant treatment of, 

145. 
feeding in, 146. 
heart in, 151. 
hemorrhages in, 150. 
perforation in, 150. 
tympanites in, 149. 

TJ. 

Ulceration of the stomach, 27. 
Umbilical arteritis, 59. 

cord, treatment of the, 55. 

gangrene, 59. 

hemorrhage, 60. 

hernia, 65. 

phlebitis, 59. 
Uraemia, 287. 

Uric acid infarctus, 280, 501. 
Urine, incontinence of, 290, 291. 

retention of, 290, 291. 
Urticaria pigmentosa, 432. 

V. 

Vagina, atresia of the, 305. 

catarrh of the, 303. 

hemorrhage from the, 305. 
Valgus, pes, 482. 
Van der Veer, 381. 



Varicella, 177. 
Variola, 176. 
Venesection, 364. 
Vesicatories, 86. 
Villate, 473. 

Vitreous body, abscess of the, 458. 
Volkmann, 484. 
Vomiting, 25, 233. 
Vulva, catarrh of the, 303. 
noma of the, 302. 



W. 

Warts, 432. 

Water, effect of, on gastric secre- 
tion, 13. 

for the newly-born, 280. 

general eifects of, 15. 

supply through rectum, 235. 

to be boiled, 14. 
Webbed fingers, 464. 
Whooping-cough, 216. 

dangers of, 69. 

prevention of, 217. 

treatment of, 219. 
Widerhofer, 489. 
Wieland, 472. 
Worms, 261. 
Wroblewski, 499. 



Z. 

Zinc in epilepsy, 410. 
Zweifel, 500. 



THE END. 



AN ELEMENTARY TREATISE 

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